Cheshire Social Worker Medicaid Fraud: Whose Therapy Was Medicaid Paying For?

A Cheshire social worker agreed to pay $145,855 in a Medicaid fraud case over allegations that she billed psychotherapy as her own work when unlicensed people provided it. The licensed name on the claim and the person delivering the care were allegedly different. For someone inside a therapy practice, that is a concrete discrepancy: you may know who saw the patient, whose credentials appeared in billing and who decided to submit the claim that way.

The Justice Department announced the civil settlement on April 10, 2019. The case concerned a licensed clinical social worker who owned a private psychology practice in Cheshire, Connecticut.

What Connecticut Medicaid Was Told

The government alleged that the social worker billed Medicaid for psychotherapy as though she had personally provided the services, while unlicensed individuals actually provided them. The settlement covered conduct from January 2016 through September 5, 2017.

The practice owner was enrolled as a Licensed Behavioral Health Clinician in Independent Practice in the Connecticut Medical Assistance Program, which includes Medicaid. That enrollment matters to the allegation. Medicaid was receiving claims for the enrolled professional’s own psychotherapy, according to the government’s account, while someone else allegedly did the work.

In its description of the billing requirement, the Justice Department cited the Connecticut Department of Social Services provider manual for that independent-practice category. The department would not pay for services provided by someone other than the provider.

The licensed professional was on the bill while someone without a license allegedly delivered the therapy. The credential did the work on paper.

Why the Rendering Provider Matters

The rendering provider is the person who actually delivers the service.

In behavioral health, the professional treating a patient and the organization submitting the bill can occupy different roles. We examine those facts against the service and date on the claim, with the payment rule for that practice and program alongside them.

The Today’s Youth LLC settlement shows why supervision deserves closer attention in this setting. The government alleged that Connecticut Medicaid claims represented services by licensed clinicians when unlicensed providers had performed them. Its announcement explained that supervising an unlicensed worker did not satisfy the independent-practice program’s requirement about who delivered the service.

That is a specific payment problem for a practice using a licensed clinician’s identity: supervising someone else’s work and personally delivering the billed therapy are different things. In Cheshire, the government alleged that the enrolled social worker billed the psychotherapy as her own. We examine the claim against the role the clinician actually played, including whether the person treated the patient or oversaw someone who did. The program and practice category matter to that examination.

An insider may see that connection from a different direction. A clinician knows who conducted the session. Someone working in billing may know whose identity was used. Putting those accounts together can explain a claim that looks complete when viewed only through its billing fields.

What Are Some Examples of Unethical Billing Practices in Counseling?

Billing counseling under the identity of a licensed professional who allegedly did not provide it is one example.

In the Behavioral Management LLC settlement, the government likewise alleged that claims represented psychotherapy by licensed staff when unlicensed personnel delivered the care.

The Settlement and Medicaid Suspension

The social worker’s agreement with the federal and state governments resolved allegations under the federal and state False Claims Acts. She agreed to pay the money back to Medicaid. She also agreed to a voluntary three-year suspension from the Connecticut Medicaid program as part of the civil settlement.

The Justice Department’s account of the investigation places the case within a larger behavioral health investigation. The Office of the Inspector General of the U.S. Department of Health and Human Services, the Medicaid Fraud Control Unit of Connecticut’s Chief State’s Attorney’s Office and the Connecticut Office of the Attorney General conducted that investigation jointly, with support from the Connecticut Department of Social Services.

Where the Claim and the Work Can Be Compared

For a health care employee who recognizes this pattern, the valuable knowledge may be quite specific: how appointments were assigned, who actually treated patients or how a licensed clinician’s identity entered the billing process. We connect that knowledge to staffing records, treatment notes and claims, and examine who made the billing decisions. You know how the practice worked from the inside. Our job is to turn that understanding into a case about the treatment Medicaid was asked to pay for.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know Who Delivered the Therapy

If the clinician on the claim was not the person doing the work, speak to one of our Whistleblower Experts about the billing you saw. We work with you to build a case around the actual treatment, staff qualifications and claims, and bring in healthcare fraud whistleblower lawyers who understand Medicaid psychotherapy billing. We stay with you from the first conversation through the pursuit of a recovery, working to build your strongest Medicaid whistleblower case.