Again, hard to know anything without knowing actual evidence, but, a practice with multiple locations is common. Licensed psychologists bill under a practice NPI II while referencing their own NPI I as the rendering provider. What do you mean by saying a licensed provider is billing under another provider's license?
Do you have actual evidence of these billing practices, or are these assumptions? Not saying what they are doing is competent, but clinical incompetence is a lot different than felony fraud, and I would not allege the latter without fairly clear proof.
Yeah- insurance billing can be overly complex at times. We have some funders where we bill under the agency NPI at the corporate address, some under my own NPI at my satellite clinic address, and some with permutations thereof. What is definitely NOT ok would be billing a service performed by a non-licensed or non-credentialled (by the insurance company) provider as if it were provided by a licensed/credentialled (or more "highly" licensed individual.
For example, if I'm both me and my colleague are licensed psychologists credentialled and eligible to bill Purple Diamond insurance for psych assessment, She can do the intake and feedback, I (or an appropriately trained/credentialled psychometrician) can do the testing, either of us could write the report, and she could do the feedback, as long as all services were performed and appropriately billed as being completed by the person who did them. Depending on the insurance company, there may need to be a primary provider listed on any insurance mandated documentation or forms. I would be certain that all notes and records contain info the specifically identifies the person who performed the service. That's not how we do it, but that might be more common in larger group practices or AMC type setting with multiple clinicians/psychometrists/intern on site- I don't know.
On the other hand- for example- say I'm credentialled with Purple Diamond but my colleague (also a licensed psychologist) is not. Purple Diamond has us bill all services under agency NPI number at corporate address. It would not be ethical/legal for her to do all of the work, have me just sign off on the report and/or be listed as primary clinician, and bill for all the services she performed as if I did them. If I did, say, the intake, scored a test, and gave feedback, we could be for my time spent doing that, by not for her time spent doing the other stuff (at least not billed under psychologist billing codes that require credentialling).
In a private pay setting, it would be different. Basically, as long as you are up front about the services you provide and who will be providing them, and they are actually performed by someone appropriately trained and licensed (if necessary) to do them, probably no-harm no-foul. Such services are often performed under a flat rate (e.g., "$4000 for a full eval, which includes interview, records review, test admin and scoring, and feedback"). In the case of insurance reimbursed services, each specific service (e.g., intake interview; test admin and scoring; feedback) is billed under a different billing CPT code (CPT= Current Procedural Terminology) which pays a specific rate for every "unit" of service. Units are typically 30 or 60 minutes depending on the code being billed, with stipulations about the total proportion of time that need to used to count as a full unit (e.g., a 53 minutes diagnostic interview could be billed as one 60 minute unit of CPT code 90791). OP- sorry if you know all this, but this board is meant for students who my not have this information.
In the case of the clinician referenced in the OP- If they are billing standard insurance codes for diagnostic interviews/intakes (e.g., 90791) I'm curious as to how they could bill 25 of these in one day. I might be wrong, but I think that one unit of 90791 is 60 minutes and that you can't bill in fractions of units. While it might not be unreasonable that some intakes take less than 15 minutes (my clients, for example, only have 18 months of history to review, and 6-9 of those months didn't have much going on). Still- it usually takes a bit longer than that to get information, get initial impressions, discuss targets of treatment and possible differential diagnosis, etc. I'd be suspicious of someone scheduling 15 minute intakes as de facto practice.
In regards to you actually having
proof of wrongdoing to take action, I think that is too high of a standard. It's the board (or regulatory/legal authorities in the case of fraud) to investigate and establish proof. I'd say if you have reasonable suspicion based on some form of direct knowledge of what's going on (e.g., beyond hearsay), you have what you need to file a complaint with the licensing board. AFAIK, your name and info would not be provided to the other clinician, at least before any more serious proceedings against them (e.g., if you were deposed or called as a witness). If your suspicions are based on hearsay from someone who claims to have seen wrongdoing, you should at least ask how they got their info and- if they are subject to ethical or legal reporting standards- if they have or plan to file a complaint. If it was another psychologist, I'd let them know that they are ethically obligated to address unethical/illegal practices of other providers.
