Universal Health Services: The Credentials Behind the Medicaid Bill

The Universal Health Services Medicaid case concerned allegations that Arbour Counseling Services billed MassHealth for mental-health treatment by staff who lacked required qualifications or supervision. The claims carried professional identities that allegedly concealed what was happening inside the clinic. For a behavioral-health employee who knows the staff, the supervision arrangements or the billing system, that is the connection at the center of the case: who provided the care, and who Medicaid was told had provided it.

Universal operated the Arbour clinic in Lawrence, Massachusetts, where a young Medicaid patient received treatment. Her mother and stepfather brought a qui tam case under the False Claims Act. It reached the Supreme Court over a question that began in the clinic: when does leaving out the truth about a provider’s qualifications make a claim for payment misleading?

The Treatment Behind the Staffing Allegations

The parents alleged that only one of the five professionals who treated their daughter was properly licensed. The Supreme Court’s account described a practitioner who diagnosed bipolar disorder with a degree from an unaccredited Internet college, and another presented as a psychiatrist who was actually a nurse without authority to prescribe medication without supervision. The wider allegations concerned some 23 Arbour employees who lacked licenses to provide mental-health services.

The district court’s account of the complaint puts the treatment in sequence. The patient began counseling at Arbour after experiencing behavioral problems in middle school. Different staff members took over her care. After the bipolar diagnosis, a nurse practitioner prescribed medication. The parents alleged that their daughter had an adverse reaction, that they left messages for the prescriber, and that she stopped taking the medication before hearing back. She subsequently had a seizure and died of another seizure months later.

The parents’ billing allegation concerned the professional services MassHealth paid for throughout that care. They alleged that the people providing those services lacked the necessary qualifications or adequate supervision. They also alleged that the staff psychiatrist became involved only when the direct providers asked for help.

That last detail matters to anyone who has worked in a clinic. A supervisor’s place on the staff roster and the supervision actually provided are different records. In this case, the parents challenged both the qualifications of the people treating their daughter and the oversight behind their work.

How Professional Identity Entered the Medicaid Claim

The alleged misrepresentation traveled into billing through professional identities and job-title codes. In the Supreme Court’s account, staff misrepresented their qualifications and licensing status to obtain individual National Provider Identification numbers. Those numbers accompanied Medicaid reimbursement claims and corresponded to particular job titles.

That connects staff qualifications to what the payer sees. A billing employee may know which identity the system places on a claim. A human-resources employee may know the qualifications behind that identity. A clinical supervisor may know whether the promised oversight happened. Put those accounts together, and the question becomes concrete: did the professional description on the bill match the service the clinic actually delivered?

The district opinion described a MassHealth rule requiring direct and continuous supervision of unlicensed staff by a fully qualified professional. It also described reimbursement as including supervision or consultation with another staff member. On the parents’ account, the public program was paying for care with supervision while the clinic failed to provide the required oversight.

We see the absurdity in treating that alleged gap as a paperwork dispute. The supervision was part of what the payment bought.

What the Massachusetts Investigations Found

Massachusetts agencies examined the staff’s qualifications and supervision after the parents complained. The district opinion identifies the Division of Professional Licensure, the Disabled Persons Protection Commission and the Department of Public Health, each with a different part of the investigation.

According to the opinion, the Disabled Persons Protection Commission concluded that the prescribing nurse lacked proper supervision. The Department of Public Health concluded that the people directly treating the patient were unqualified to do so without supervision, and that the psychiatrist neither provided nor was qualified to provide the required oversight.

The licensing division also reached a consent agreement with the practitioner who had used the psychologist title. She agreed to stop referring to herself as a psychologist while unlicensed.

What the Supreme Court Held

The Supreme Court held that a payment claim can be misleading because of what the provider leaves out. Its June 16, 2016 opinion explained how: a bill describes the goods or services provided, but hides violations of requirements important to payment, turning that description into a misleading half-truth. Our False Claims Act page on the ruling covers the materiality test it set.

In the Arbour allegations, the professional identity supplied with the claim was part of the representation. The missing information concerned the qualifications and supervision behind that identity.

Universal argued that the rules governed participation in the program, not payment of its bills. The Court said that label does not decide whether a bill is false. What matters is the importance of the missing information to the government’s payment decision.

Why the Missing Supervision Mattered to Payment

The Supreme Court required a clear connection between the withheld information and the government’s decision to pay. For this kind of Medicaid provider case, the important facts join the service represented on the claim to the missing qualification or supervision and its significance to the payer.

The practical question reaches beyond whether an agency received a complaint. We examine what the government actually knew about the services being billed, when it knew it, and how that knowledge connects to payment. The staff’s internal account, the investigation and the payment record answer different parts of that question. Our work is to bring them together around the particular claims.

What Evidence Is Needed to Prove Fraud?

In a staff-qualification case, the evidence connects the billed professional identity to the person who delivered the service, the required qualifications and supervision, and what the provider knew. The Arbour allegations show why personnel files, clinical oversight and billing records belong in the same account.

A separate federal review illustrates how those checks can come apart. In its Georgia Comprehensive Program Integrity Review, published in December 2014, the Centers for Medicare & Medicaid Services found that Georgia checked expiration dates but did not verify restrictions with out-of-state licensing boards. The review separately found that paper claim forms did not capture the identifying numbers of ordering and referring professionals. They illustrate the separate work of identifying a provider and verifying the qualifications behind the identity.

The 2012 Journal of Information Systems Applied Research paper Applying Business Intelligence Concepts to Medicaid Claim Fraud Detection showed how existing Medicaid payment data could be reorganized for fraud detection. Its discussion of statistical screening makes room for the knowledge an insider brings:

For a clinic employee, that expertise may be as specific as knowing who actually supervised a clinician, or why the qualifications in a personnel file differ from the identity used in billing. We connect that knowledge to the claims and the decisions inside the provider. The healthcare employee who understands the mismatch may sit in clinical operations, human resources or billing.

Universal Health Services’ Separate Inpatient-Care Settlement

Universal agreed to pay $117 million in a national inpatient-care settlement announced on July 10, 2020, resolving a separate group of cases. The government alleged unnecessary inpatient admissions and stays, missing services, and inadequate staffing, training or supervision. Those allegations again connected behavioral health care billing with the care and staffing behind it.

Can You Get Paid for Reporting Medicaid Fraud?

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

You Know Who Provided the Care

If the qualifications behind your clinic’s claims differ from what Medicaid was told, speak to our Whistleblower Experts about who really provided the care. We work beside you to build your strongest Medicaid whistleblower case and bring in Medicaid fraud whistleblower lawyers who understand behavioral-health staffing and payment requirements.