10 Easy Ways to Lose Your License: Surprisingly Common Forms of Insurance Fraud

By Barbara Griswold, LMFT

Navigating the Insurance Maze: The Therapist’s Complete Guide to Working With Insurance – And Whether You Should
(www.navigatingtheinsurancemaze.com)

Most of us become therapists because we want to help people. But in all our coursework, we may never have taken a class in dealing with insurance. This lack of knowledge can lead us to make billing decisions that we don’t even know are illegal or unethical. Our resentment about insurance contract discounts may also cause us to be less than honest in our billing. Or we may bend the truth in a well-intentioned attempt to help our clients afford therapy.

It is a challenge to stay ethical when you feel the cause is so just, and the chances of getting caught appear so small. However, the consequences for fraud can be quite severe, and include repaying the insurance company, fines, loss of license, and jail.

So how do you know when you’ve entered into the territory of insurance fraud? Michael Brandt, a fraud investigator from HealthNet Insurance, writes that “health care fraud is deception or misrepresentation by providers…with knowledge that the deception could result in some unauthorized payment or benefit.”¹ Note that the definition requires intentional misrepresentation on the provider’s part.

Here’s a quick rundown of some common types of insurance fraud:

Diagnosing with reimbursement in mind. I can’t tell you how often I get calls from therapists asking me “what diagnosis should I use on claims so that I can be sure to be paid?” You need to give the most accurate diagnosis, without regard for reimbursement.

Diagnosing a mental illness when one does not exist: This may be tempting when seeing a client for self-esteem, communication, career, or personal growth issues, but there is no mental illness present. But remember — this is medical insurance, and plans typically won’t cover only a V-code diagnosis.
Changing Diagnoses: It may be tempting to give a more serious diagnosis than your client actually has when you know it will afford better coverage. For example, if your client might pay a lower co-payment or get unlimited sessions for a particular diagnosis, you might think about giving that diagnosis. But a diagnosis should not be changed unless a mistake was made in the original diagnosis or unless the client’s condition changed.
Under-diagnosing: For example, your client may not want to document his substance abuse on a claim. But it could be considered fraud if you instead put Adjustment Disorder on the claim when that is not what you are treating. Why? Because the plan might have made different authorization or reimbursement decisions if the correct diagnosis had been known.

Billing insurance for a missed session without making it clear on the claim that it was missed. If you do bill, you must not use a CPT (Current Procedural Terminology) code on the claim that would give the impression that a session took place — ask the plan what code to use. Most plans will not pay for missed sessions; check your contract (if you are a network provider) or call the plan.
Charging the plan more than your usual fee. In your practice, you need to have a “full fee” that you charge. You may have a sliding-fee scale, but you may not “slide up” from your full fee when billing insurance. It would be fraud, for example, to charge a client’s insurance $150 per session if you would not charge a self-pay client this amount. (This issue does not apply to network therapists, who have a contracted fee).
Waiving client co-payments in advance. You may not tell the client he doesn’t need to pay his co-payment or deductible. Say your contracted fee is $60, and your client’s co-payment is $20, but you agree in advance to waive his portion. In essence, this is agreeing to see him for a total of $40 but billing insurance for $60, which is fraud. (While it is not acceptable to waive co-payments in advance, you may forgive unpaid balances, if you have made reasonable attempts to collect).
Billing for phone sessions using a CPT code for in-person therapy. Most plans will not reimburse for phone sessions — check your contract if you are a network provider or call the insurance plan to be sure. If they allow you to bill for this, be sure to get preauthorization (if needed) and use the correct CPT Code on the claim.
Submitting a claim for individual therapy when you saw a couple, or vice versa. If you know the plan doesn’t cover couples sessions, it is fraud to use a CPT code for individual therapy on the claim in order to be reimbursed. Again, the plan has the right to know the type of service you are providing in order to make a reimbursement determination.
Providing couples therapy and billing both partners’ insurance companies for individual sessions. Again, because the CPT Codes are different, this would be misrepresenting the service provided. You may bill both insurance companies for the couples session, but you would need to bill the primary plan first (using the couples therapy CPT code), then include details of their payment when billing the secondary plan.
Having someone else sign your claims, or if unlicensed, signing in a way that makes you appear licensed. If you are not covered by the plan, you may not have a plan provider or covered license holder sign for you. Be sure to give the name and license status of the treating provider. If unlicensed providers are covered by the plan, the treating therapist and supervisor should both sign, identifying themselves on the claim as “treating therapist” and “supervising therapist.”
Rewriting case notes before an insurance plan review or audit. This may be equivalent to falsifying documents.
Changing service dates, or “splitting” two-hour sessions. You may be tempted to change dates on the claim so that a session will be covered by an authorization. Or if the plan won’t cover a two-hour session, you might want to bill for two one-hour sessions on different days. However, this would be misrepresentation.

“Do not allow yourself to be misled or manipulated by your clients who convincingly ask for your assistance in reducing their financial burdens at the expense of their insurance companies,” writes Mary Riemersma, Executive Director of The California Association of Marriage and Family Therapists. “You are the therapist, the one in control of the situation, and you should be the role model.”² You would essentially be entering into an illicit conspiracy with your client against the insurance company, an agreement which could taint the relationship between you and your client, and negatively impact your treatment.

Barbara Griswold, MFT, is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance–and Whether You Should (www.navigatingtheinsurancemaze.com). Barbara provides consultations and training on insurance issues and practice building to therapists all over the country. Visit her website to view her workshop schedule, sign up to receive her free monthly insurance newsletter, or schedule a phone consultation. In private practice in San Jose, California, Barbara serves on the California Association of Marriage and Family Therapists’ Ethics Committee.

References
¹ – Michael Brandt, “Health Care Fraud Affects Everyone.” Health Net Physician News (Spring 2000), p.7.
² – Mary Riemersma, “What is Insurance Fraud?” The California Therapist, (March/April 2001).

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10 Easy Ways to Lose Your License: Surprisingly Common Forms of Insurance Fraud

By Barbara Griswold, LMFT

Navigating the Insurance Maze: The Therapist’s Complete Guide to Working With Insurance – And Whether You Should
(www.navigatingtheinsurancemaze.com)

Here’s a quick rundown of some common types of insurance fraud:

Diagnosing with reimbursement in mind. I can’t tell you how often I get calls from therapists asking me “what diagnosis should I use on claims so that I can be sure to be paid?” You need to give the most accurate diagnosis, without regard for reimbursement.

Diagnosing a mental illness when one does not exist: This may be tempting when seeing a client for self-esteem, communication, career, or personal growth issues, but there is no mental illness present. But remember — this is medical insurance, and plans typically won’t cover only a V-code diagnosis.
Changing Diagnoses: It may be tempting to give a more serious diagnosis than your client actually has when you know it will afford better coverage. For example, if your client might pay a lower co-payment or get unlimited sessions for a particular diagnosis, you might think about giving that diagnosis. But a diagnosis should not be changed unless a mistake was made in the original diagnosis or unless the client’s condition changed.
Under-diagnosing: For example, your client may not want to document his substance abuse on a claim. But it could be considered fraud if you instead put Adjustment Disorder on the claim when that is not what you are treating. Why? Because the plan might have made different authorization or reimbursement decisions if the correct diagnosis had been known.

Billing insurance for a missed session without making it clear on the claim that it was missed. If you do bill, you must not use a CPT (Current Procedural Terminology) code on the claim that would give the impression that a session took place — ask the plan what code to use. Most plans will not pay for missed sessions; check your contract (if you are a network provider) or call the plan.
Charging the plan more than your usual fee. In your practice, you need to have a “full fee” that you charge. You may have a sliding-fee scale, but you may not “slide up” from your full fee when billing insurance. It would be fraud, for example, to charge a client’s insurance $150 per session if you would not charge a self-pay client this amount. (This issue does not apply to network therapists, who have a contracted fee).
Waiving client co-payments in advance. You may not tell the client he doesn’t need to pay his co-payment or deductible. Say your contracted fee is $60, and your client’s co-payment is $20, but you agree in advance to waive his portion. In essence, this is agreeing to see him for a total of $40 but billing insurance for $60, which is fraud. (While it is not acceptable to waive co-payments in advance, you may forgive unpaid balances, if you have made reasonable attempts to collect).
Billing for phone sessions using a CPT code for in-person therapy. Most plans will not reimburse for phone sessions — check your contract if you are a network provider or call the insurance plan to be sure. If they allow you to bill for this, be sure to get preauthorization (if needed) and use the correct CPT Code on the claim.
Submitting a claim for individual therapy when you saw a couple, or vice versa. If you know the plan doesn’t cover couples sessions, it is fraud to use a CPT code for individual therapy on the claim in order to be reimbursed. Again, the plan has the right to know the type of service you are providing in order to make a reimbursement determination.
Providing couples therapy and billing both partners’ insurance companies for individual sessions. Again, because the CPT Codes are different, this would be misrepresenting the service provided. You may bill both insurance companies for the couples session, but you would need to bill the primary plan first (using the couples therapy CPT code), then include details of their payment when billing the secondary plan.
Having someone else sign your claims, or if unlicensed, signing in a way that makes you appear licensed. If you are not covered by the plan, you may not have a plan provider or covered license holder sign for you. Be sure to give the name and license status of the treating provider. If unlicensed providers are covered by the plan, the treating therapist and supervisor should both sign, identifying themselves on the claim as “treating therapist” and “supervising therapist.”
Rewriting case notes before an insurance plan review or audit. This may be equivalent to falsifying documents.
Changing service dates, or “splitting” two-hour sessions. You may be tempted to change dates on the claim so that a session will be covered by an authorization. Or if the plan won’t cover a two-hour session, you might want to bill for two one-hour sessions on different days. However, this would be misrepresentation.

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