Behavioral Management: Short Group Sessions Allegedly Billed as Individual Biofeedback Therapy

In the Behavioral Management fraud case, the practice and its owner agreed to a $100,843 civil settlement over allegations that they billed Medicaid for individual biofeedback psychotherapy while providing short group sessions without biofeedback through unlicensed personnel. For someone who knew the children’s program, the alleged differences concerned the work itself: how long a session lasted, who attended, what treatment happened and who provided it.

Behavioral Management LLC was a private behavioral health practice in North Haven, Connecticut. It provided after-school and school-break programs for children with behavioral and mental health issues. The practice was enrolled as both a Behavioral Health Clinician Group and a Professional Counselor Group in the Connecticut Medical Assistance Program, which includes Medicaid.

What CPT 90876 Represented

According to the government’s account of the claims, CPT 90876 represented individual psychotherapy incorporating biofeedback, face-to-face with the patient. The government alleged that Behavioral Management and its owner misrepresented the session’s duration, its individual format, the use of biofeedback and the qualifications of the person delivering it.

The time. The claims represented 45 minutes of psychotherapy. The government alleged that the sessions actually lasted 20 minutes. That difference concerns the treatment interval, something a person delivering or scheduling the session would recognize. The time a child spent in an after-school program and the time spent receiving the particular therapy billed are different questions.

The format. The billed service was one-on-one psychotherapy. The government alleged that the children instead received group services. Calling a group session individual therapy changes what Medicaid is told it bought. A child’s attendance in the group does not describe an individual encounter with a clinician.

The treatment. The claims included biofeedback. The government alleged that no biofeedback was provided. This was a claim about the treatment itself, separate from whether the session lasted long enough or whether the child attended alone.

The worker. The claims represented that a licensed provider had delivered the services. The government alleged that an unlicensed individual delivered them.

In those allegations, we see an entire session rewritten on paper. Longer treatment, one-on-one therapy, biofeedback, a licensed clinician: Medicaid was billed for all of it. The government alleged the children received none of it.

Why the Staff Qualification Mattered

The owner had a bachelor’s degree in social work, but the Justice Department said he was not a licensed behavioral health provider in Connecticut. His education and the practice’s enrollment did not answer the government’s allegation that the claims represented services by a licensed provider when an unlicensed person performed them.

An organization’s payer enrollment, a worker’s professional qualifications and the identity of the person who actually delivers care are separate facts. The company name at the top of a claim tells only part of that story. We look at the service and the person together, because the bill speaks for both.

The case also shows why calling everything upcoding can hide what happened. Here, the alleged qualification mismatch concerned the person in the room. The time and treatment allegations concerned what that person did. An insider may know one part particularly well: a biller may know how the service was described, while a program worker may know who actually led the group. Together, those accounts let us compare the bill with what happened in the room.

What Other Behavioral Billing Cases Show

The same distinction between an enrolled practice and the person delivering care appeared in another Connecticut case. In its Today’s Youth settlement announcement, the Justice Department described allegations that Medicaid claims represented services by licensed clinicians when unlicensed providers performed them. The Justice Department said that, in this independent-practice program, supervising an unlicensed worker did not make the work billable as a licensed clinician’s.

That is a close parallel to the qualification issue at Behavioral Management. A supervisor’s role and the identity of the worker delivering a session answer different questions. Someone familiar with staffing can see a difference that the billing description conceals.

The format issue appeared in a different setting at Good Shepherd Catholic School. The Oklahoma City nonprofit school settled allegations that it billed TRICARE for applied behavior analysis services represented as one-on-one care when the services were provided in groups. The alleged mismatch concerned how the service was delivered.

Exemplary Behavior illustrates how these representations can overlap. Its settlement concerned allegations involving TRICARE applied behavior analysis claims, including group therapy billed as individual care and billing under a provider who did not render the services. The government also alleged double billing and services that never occurred.

These cases make different parts of the same claim visible: the service, its format and the worker. Behavioral Management’s alleged absence of biofeedback adds a specific treatment mismatch to that comparison. That is why we examine what the bill says happened against the work people actually saw.

The Behavioral Management Settlement

The Justice Department announced the agreement on February 1, 2021. Behavioral Management and its owner agreed to reimburse Medicaid for conduct occurring from January 1 through December 31, 2014. The civil settlement resolved allegations under the federal and state False Claims Acts.

The case grew out of a larger behavioral health investigation jointly conducted by the U.S. Department of Health and Human Services Office of Inspector General, the Medicaid Fraud Control Unit of the Chief State’s Attorney’s Office and the Connecticut Office of the Attorney General.

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

What Evidence Is Needed to Prove Fraud?

We work with you to connect the bill to what happened in the room. For a case like Behavioral Management, that means examining the claimed therapy alongside the session time, group attendance and the person who actually provided care.

Attendance records, staff schedules, credentials and contemporaneous treatment notes can help us make that comparison. A schedule can identify who was assigned to a session. A treatment note can describe the work recorded for that child. The claim shows what the payer was asked to buy. We examine those records together with what you know about the program, rather than treating any one of them as the whole story.

You may know the group as a staff member or know the claims through billing work. We work with you to connect that knowledge to the payment the practice sought and the decisions behind the description of care.

You Know What Happened in the Room

If you know group sessions became individual therapy on the bill, speak to one of our whistleblower experts about the care you saw. We build your strongest case with you and bring in behavioral health fraud whistleblower lawyers who understand Medicaid billing and rendering-provider qualifications. From that first conversation through the case, we stay on your side of the table.