BRIAN WILLIAM GRANT, Ph. D.

Brian Grant is an individual provider in Indianapolis, Indiana, enrolled in Indiana Medicaid under NPI 1063574994. Almost all of his Medicaid payments, about 90 percent, come from a single code for one hour psychotherapy sessions, which paid $1,205,859 over 72 months. On April 1, 2019, the claim lines attributed to him added up to more service time than a single person can deliver in one day, with an implied 12.5 to 24.1 hours of hands-on care, and the claims came in through three different billing organizations. His per patient per month amounts also sit above the typical provider on several psychotherapy codes, for example $309 against a typical $191 on the one hour code. These are records observations only, and there may be ordinary explanations such as claims submitted under his number for services delivered by other clinicians.

1. 01NPI 1063574994 is registered to BRIAN GRANT, an individual provider in INDIANAPOLIS, IN, with taxonomy 103TH0100X and Medicaid home state IN. records 1
2. 02Code 90837 (Psychotherapy, 1 hour) accounts for $1,205,859 paid over 72 months, 90 percent of this provider's Medicaid dollars, at $309 per patient-month, which ranks at the 85th percentile of all providers billing this code, where typical is $191. records 2
3. 03Code 90846 (Family psychotherapy without patient, 50 minutes) accounts for $99,448 paid over 35 months, 7 percent of Medicaid dollars, at $150 per patient-month, at the 71st percentile against a typical $113. records 3
4. 04Code 90832 (Psychotherapy, 30 minutes) accounts for $27,325 paid over 10 months, 2 percent of Medicaid dollars, at $112 per patient-month, at the 84th percentile against a typical $59. records 4
5. 05Smaller amounts were paid on code 90847 ($3,480 over 1 month), code 90834 ($2,433 over 2 months) and code 90791 ($1,150 over 1 month), each 0 percent of the provider's Medicaid dollars. records 5, 6, 7
6. 06The provider is at evidence tier 2 (impossible volume with concurrency) under detector D2, with dollars at risk of $703,223, described as the figure of the detector that set the tier and not a sum. records 8
7. 07The stated detector reasons are that the provider billed more hands-on hours than a day holds in 1 month, peaking at 14.3 hours per day across 3 billing organizations, and that 90 percent of Medicaid dollars are on codes with a history of abuse. records 8
8. 08On 2019-04-01 a flag of IMPOSSIBLE_BY_LINE_COUNT was recorded, with implied hours per clinician calendar day for personal services of 12.5, a lower bound of 24.1 and a point estimate of 18.7, covering $41,404 on code 90837 across 3 billing organizations, using rate source p50 per line. records 9

Request from the provider and the three billing organizations the appointment schedules, session start and stop times, signed session notes and rendering clinician identity for all 90837 claim lines dated 2019-04-01 and for a sample of high volume months across the 72 month period. Reconcile the rendering provider on each line against the individual NPI 1063574994 to determine whether services were personally performed or delivered by supervised or employed clinicians, and obtain any group practice reassignment agreements. Verify screening and enrollment status and revalidation history under 42 CFR 455.410, which requires screening under subpart E as a condition of enrollment and revalidation at least every 5 years. If the review supports a credible allegation of fraud, the State Medicaid agency must consider payment suspension and refer to the Medicaid Fraud Control Unit under 42 CFR 455.23(a) and (d), and evaluate exposure for claims for items or services not provided as claimed under 42 CFR 1003.200. Treat the $703,223 dollars at risk figure as a detector output, not a calculated overpayment.

• Claim lines may have been submitted under this individual NPI for services personally performed by other clinicians under supervisory or incident to billing conventions, which would explain hours that exceed a single day.
• The presence of 3 billing organizations on the same day may reflect legitimate employment or contracted arrangements at multiple sites rather than duplicate billing.
• The implied hours figures come from a rate source of p50 per line and carry a range from 12.5 to a lower bound of 24.1 and a point estimate of 18.7, so the underlying time estimate is modeled and should be replaced with actual documented session times.
• The dollars at risk figure of $703,223 is described in the evidence as the figure of the detector that set the tier and not a sum, so it should not be treated as an established overpayment.
• Percentile rankings compare per patient-month amounts to other billers and may reflect a caseload with higher acuity or longer sessions rather than improper coding.
• Claims data lag, adjustments, voided lines and reprocessed claims can inflate apparent single day volume and should be ruled out before conclusions are drawn.