DEBRA RENADE WHITFIELD

Debra Whitfield is an individual behavioral health provider in Las Vegas, Nevada, enrolled in Nevada Medicaid. Most of her Medicaid dollars come from two codes: intensive outpatient psychiatric services per diem, at $2,361,251 paid over 36 months, and psychophysiological therapy with biofeedback, at $839,264 paid over 33 months. In four separate months of 2018, the one hour psychotherapy and biofeedback lines billed under her identifier add up to more hands-on hours than a calendar day contains, reaching 25.6 implied hours in one day in March 2018. In each of those months the claims came in through three or four different billing organizations. These records do not by themselves show who actually performed the services, so the plan should obtain scheduling and time records before drawing any conclusion.

1. 01NPI 1073891859 is registered to DEBRA WHITFIELD, an individual provider in Las Vegas, NV, with taxonomy 103K00000X and Medicaid home state NV. records 1
2. 02Code S9480, intensive outpatient psychiatric services per diem, accounts for $2,361,251 paid over 36 months and 68 percent of this provider's Medicaid dollars, at $1,400 per patient-month against a typical $946, ranking at the 78th percentile of providers billing this code. records 2
3. 03Code 90876, psychophysiological therapy with biofeedback 45 minutes, accounts for $839,264 paid over 33 months and 24 percent of this provider's Medicaid dollars, at $493 per patient-month against a typical $392, ranking at the 66th percentile. records 3
4. 04Code 90837, psychotherapy one hour, accounts for $156,420 paid over 26 months and 5 percent of this provider's Medicaid dollars, at $240 per patient-month against a typical $191, ranking at the 69th percentile, and this code family has a history of abuse. records 4
5. 05Code 90901, biofeedback training, accounts for $22,306 paid over 7 months at $121 per patient-month against a typical $45, ranking at the 69th percentile. records 7
6. 06Codes 99214 and 99213 account for $36,126 paid over 3 months and $23,203 paid over 2 months, each 1 percent of this provider's Medicaid dollars. records 5, 6
7. 07The provider is placed at evidence tier 2, impossible volume with concurrency, under detector D2, with dollars at risk of $744,791, described as the figure of the detector that set the tier and not a sum, and reasons stating more hands-on hours billed than a day holds in 4 months, peaking at 25.6 hours per day across 4 billing organizations. records 8
8. 08For January 1, 2018, the flag IMPOSSIBLE_BY_LINE_COUNT records implied hours per clinician calendar day of personal services of 24.4, with a lower bound of 37.3 and point estimate of 36.6, $134,132 paid, codes 90837 and 90876, and 3 billing organizations, using rate source p50 per line. records 11
9. 09For February 1, 2018, the flag records implied hours per clinician calendar day of 23.2, with a lower bound of 35.0 and point estimate of 34.7, $116,570 paid, codes 90837 and 90876, and 4 billing organizations. records 9
10. 10For March 1, 2018, the flag records implied hours per clinician calendar day of 25.6, with a lower bound of 37.3 and point estimate of 38.4, $142,614 paid, codes 90837 and 90876, and 4 billing organizations. records 10
11. 11For May 1, 2018, the flag records implied hours per clinician calendar day of 18.4, with a lower bound of 27.5 and point estimate of 27.6, $98,849 paid, codes 90837 and 90876, and 3 billing organizations. records 12

Request from the provider and from each of the four billing organizations the following for January through May 2018: appointment schedules, sign-in sheets, session start and stop times, and treatment notes for all lines billed under codes 90837 and 90876. Request claim level detail identifying the rendering provider versus the billing provider for every line attributed to NPI 1073891859, along with payroll or contractor records for any supervised or employed clinicians whose work may have been billed under this identifier. Request the intensive outpatient program per diem documentation supporting code S9480, including daily attendance logs, to test whether per diem days overlap with the same day one hour psychotherapy and biofeedback lines. Verify enrollment and screening status and revalidation date 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 records review supports a credible allegation of fraud, the state Medicaid agency must consider payment suspension under 42 CFR 455.23(a) unless good cause exists not to suspend or to suspend only in part, and must refer the matter to the Medicaid Fraud Control Unit under 42 CFR 455.23(d). Preserve the file for possible civil monetary penalty exposure under 42 CFR 1003.200 for claims for items or services not provided as claimed.

• The implied hours are derived from line counts and a median rate per line, described as rate source p50 per line, so a coding or unit reporting convention could inflate the calculated time without any service being missing.
• Services billed under an individual NPI may have been performed by supervised clinicians, students or employed staff under a supervisory billing convention, which would explain hours exceeding a single person's day.
• The presence of three to four billing organizations may reflect legitimate employment or contracting at multiple clinics, or a shared billing agent submitting under the same identifier, rather than duplicate submission.
• High per patient-month amounts and percentile ranks reflect comparison to all providers billing the same code and may be explained by a higher acuity caseload or an intensive outpatient program model.
• Claims data lag, adjustments, voids and reprocessed or appealed lines can cause the same service to appear more than once in a snapshot; reconcile against final adjudicated and post-appeal data.
• The note that the psychotherapy code family has a history of abuse is a general program observation and is not evidence about this provider.