Arbour Counseling Services: The Credentials on the Claim

Arbour Counseling Services’ mental health billing put Universal Health Services before the Supreme Court over Medicaid claims that allegedly concealed missing licenses and supervision. The claims described treatments and professional roles that the staff allegedly lacked the qualifications to provide. For someone inside a clinic, that gap is concrete: the person treating the patient, the person supervising the work, and the credentials used to get paid.

Arbour was a mental health facility in Lawrence, Massachusetts, owned and operated by a UHS subsidiary. The case began with a patient’s mother and stepfather, who brought a False Claims Act case after learning about the qualifications of the people who had treated their teenage daughter. An Arbour counselor had told them that few employees were licensed and supervision was minimal. The federal government declined to join the case.

The Supreme Court’s account of the complaint described a practitioner presented as a psychiatrist who was actually a nurse without authority to prescribe medication without supervision. Another practitioner presented herself as a psychologist with a doctorate from an unaccredited internet college, even though Massachusetts had rejected her license application. According to that account, only one of the five professionals who treated the teenager was properly licensed. Their patient suffered seizures and died. The family’s billing allegations grew out of the care behind those professional titles.

What Arbour’s Medicaid Claims Represented

Arbour’s claims allegedly represented both a treatment and the qualifications of the person providing it. The Supreme Court described payment codes for individual therapy, family therapy and preventive medication counseling. National Provider Identification numbers added professional identities to those services.

According to the complaint, employees obtained NPI numbers identifying themselves as licensed social workers or licensed mental health counselors even though they lacked those licenses. The Court described one worker who used an identifier associated with a clinical social worker despite lacking the required credentials and license. A provider identifier carried the professional title into the reimbursement request.

The complaint’s representative medication-counseling claim makes the allegation specific. It identified a May 6, 2009 claim under CPT code 99404 for preventive medication counseling, submitted to MassHealth through Massachusetts Behavioral Health Partnership. The complaint alleged that the claim for the nurse’s work was false and that the payer reimbursed UHS.

In health care billing, a license concerns the professional’s authority to practice. Payer enrollment and contracts establish the reimbursement relationship. At Arbour, the allegations connected those layers through credentialing and recertification reports that the family said enabled payment for unqualified clinicians.

The alleged misrepresentation traveled all the way to the claim.

The Missing Supervision Records

The complaint alleged a clinic-wide supervision failure, reaching beyond the practitioners who treated the family’s daughter. Its account of the state investigation put the scale plainly:

The complaint also said the clinic director acknowledged having no documentation of clinical supervision for twenty therapists before January 2012. It described him as admitting that he was:

The same complaint alleged that Arbour employed no psychologist who met MassHealth’s licensing requirements to supervise its unlicensed practitioner. It also described a later investigation finding an unlicensed therapist who had gone without supervision for more than eight months despite needing biweekly supervision.

We see the absurdity: the person running the clinic allegedly did not know supervision had to happen regularly or be documented. For staff working under that director, the supervision schedule and the missing notes would tell a story the billing codes left out.

Universal Health Services and the Supreme Court’s Decision

In the Universal Health Services case, the Supreme Court held on June 16, 2016 that misleading omissions in a payment claim can support a False Claims Act case. The Court set aside the First Circuit’s judgment and sent the case back for reconsideration of whether the complaint sufficiently alleged a False Claims Act violation. It assumed the complaint’s facts were true at that stage and did not decide fraud liability. The Court’s explanation focused on claims that make specific statements about goods or services while hiding violations that matter to payment and make those statements misleading. This is called implied false certification.

Here, the alleged omissions concerned the qualifications and supervision behind the mental health services billed to Medicaid. In Arbour’s case, the treatment codes and professional identifiers supplied the specific representations. The allegedly missing qualifications supplied the concealed facts.

UHS had argued that submitting a claim involved no representations. We find that a remarkable position: the bill named the treatment and the kind of professional, yet supposedly said nothing about either. The Court looked at what the claims actually said through their codes. A clinic billing for a particular treatment by a particular kind of professional is telling the payer what it bought.

Why the Payment Decision Mattered

The Court asked whether the hidden facts mattered to the government’s decision to pay. UHS argued that the government had to label a requirement a condition of payment. The Court looked beyond the label to what the requirement meant in practice.

The family’s complaint made its payment allegation directly: UHS’s credentialing and recertification statements allegedly enabled reimbursement that Massachusetts Behavioral Health Partnership would otherwise have refused. That is where the personnel file, the supervision record and the paid claim meet. Our whistleblower experts work with insiders to understand those connections and what the business knew about them.

The Person Who Treated the Patient

The difference between the worker who delivered care and the professional represented on a claim appears in other mental health billing cases. In its April 6, 2021 announcement concerning Today’s Youth, the Justice Department described a settlement over allegations that the company billed Connecticut Medicaid as though licensed clinicians had provided services actually delivered by unlicensed workers.

Arbour’s allegations concerned workers using identifiers associated with qualifications they allegedly lacked, alongside missing supervision. The Today’s Youth allegations concerned billing as though licensed clinicians had performed the work. Both accounts connect the claim’s professional identity to the person who actually treated the patient.

A clinician may know who provided the session and whether a supervisor was involved. Someone handling credentials may know what the license file showed and what the payer was told. Someone working in healthcare billing may know which provider identifier went on the claim. Those different views of the same treatment are valuable because they connect the clinic’s daily work to its request for government money.

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

You Know Who Did the Work

If the credentials on your clinic’s claims do not match the people delivering or supervising treatment, speak to one of our Whistleblower Experts about the credentials on those claims. We work beside you to build the case around the clinical work, the credentialing decisions and the billing, and bring in mental health fraud whistleblower lawyers who understand provider qualifications and Medicaid payment. You bring the view from inside the clinic; we bring the expertise and partnership to pursue it with you.