Cascade Behavioral Health Hospital: State Investigators Found Unlicensed Staff Providing Clinical Services Billed as Licensed Professional Care

State behavioral health licensing regulators and Medicaid program integrity investigators found that Cascade Behavioral Health Hospital LLC had employed individuals without the required clinical licensure to provide individual therapy, group therapy, and clinical assessment services to psychiatric inpatients, and had billed those services to Medicaid and commercial insurance payers using billing codes that specified licensed professional provider credentials — submitting claims that misrepresented the credentials of the individuals who actually provided the billed services.DOCUMENTED

Mental health and behavioral health services are subject to state licensure requirements that specify the credentials required to provide different categories of clinical service — individual therapy, group therapy, psychiatric assessment, medication management, and others. Medicaid and commercial insurance billing for these services is tied to provider credentials: different service codes require different provider qualifications, and billing for a service under a licensed professional code when the service was delivered by an unlicensed or differently-credentialed individual constitutes a misrepresentation of provider credentials that makes the claim false.REVIEWED

The Credential Requirements

State behavioral health licensure law in the jurisdiction where Cascade operates specifies that individual therapy must be provided by a licensed clinical social worker, licensed professional counselor, licensed psychologist, or other licensed mental health professional, and that billing for these services under the applicable codes requires the services to be rendered by such a licensed individual. Individuals who are working toward licensure — completing post-graduate supervised hours — may provide clinical services, but their services are typically billable only at different rates under supervision codes, not under the independent licensed provider codes that Cascade submitted.REVIEWED

The investigation found that Cascade had hired individuals as therapists and counselors who held bachelor's-level credentials, were enrolled in graduate programs, or had completed graduate programs but had not yet obtained state licensure. These individuals were providing therapy services to inpatient psychiatric patients — services for which licensure is required both to protect patients and to ensure billing accuracy. The hospital's billing department was submitting claims for these services using the licensed professional provider codes applicable to the supervising licensed staff rather than the unlicensed staff who were actually providing the sessions.DOCUMENTED

Supervision Documentation

In behavioral health settings, clinicians who are working toward licensure may provide supervised clinical services under the oversight of a licensed supervisor, and in some states these services are billable under specific supervision codes at lower rates than independent licensed provider services. For this supervised provision model to be lawful and appropriate for billing, the supervision must be genuine — the licensed supervisor must be available, must review the work, and must document the supervisory relationship in a manner that supports the billing.REVIEWED

Investigators found that the supervision arrangements at Cascade were inadequate to justify even the supervised service billing model — licensed supervisors were responsible for case supervision loads that made meaningful session-by-session supervision impractical, supervision documentation was inconsistent and in some cases appeared to have been created after the fact rather than contemporaneously with the clinical encounters, and in the most concerning cases, services billed under a supervising licensed provider's credentials were provided during periods when the supervising provider was not on-site and could not have been conducting live supervision.DOCUMENTED

Billing submissions used individual licensed provider codes for sessions that state investigators determined were provided by staff who did not hold the licensure those codes require — with the supervising licensed clinician's credentials applied to sessions the supervisor did not conduct or in some cases was not present to observe.

Patient Safety Dimensions

The credential misrepresentation has a patient safety dimension that goes beyond the billing compliance issue. Patients receiving inpatient psychiatric services have an interest in knowing that the clinical staff treating them meet the professional qualifications that the hospital represents. Licensure requirements exist in part to ensure that clinicians providing therapy have completed the education, supervised experience, and examination requirements designed to establish a baseline level of professional competence. Patients who consented to treatment based on representations about the clinical staff credentials they were receiving did not receive what was represented.DOCUMENTED

State regulators required Cascade to immediately verify the licensure status of all staff providing billable clinical services, to terminate the billing arrangements that did not match actual provider credentials, to implement a credential verification process for all clinical staff hiring, and to provide affected Medicaid and commercial payers with amended claims reflecting the correct provider credentials and applicable billing codes — which in most cases reduced the billable amount for affected sessions. A civil penalty was assessed for the credential misrepresentation violations.DOCUMENTED

Patients who received services at Cascade Behavioral Health Hospital may request from the hospital the credentials of the clinical staff who provided their services. Patients who believe they received services from staff who were not qualified as represented have the right to file complaints with the state behavioral health licensing board, which is empowered to investigate and take action against unlicensed practice regardless of whether the facility or individual self-identifies the issue.REVIEWED

Patient Rights and Provider Credentials

Healthcare patients have the right to ask about the credentials of the individuals providing their care — including in behavioral health inpatient settings. Patients who want to verify the licensure of a clinical staff member can ask the staff member directly for their license number and license type, and then verify that information through the state licensing board's public license lookup system. Most state behavioral health licensing boards maintain searchable public databases of licensed clinicians that anyone can access online. Patients who discover that they received services from unlicensed or differently-credentialed staff than what was represented should file complaints with both the state behavioral health licensing board and the state insurance department if insurance was billed for the services. These complaints create a regulatory record that contributes to ongoing oversight of the facility's clinical staffing practices and can trigger an investigation if similar complaints from multiple patients create a pattern of concern.

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