A DSM5 diagnosis can be something as simple as a phobia of airline travel. 300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed places). All one has to do is state to one of these licensed therapists on line that one has a phobia of flying and having Sparky helps that. The professional then has to sign a letter saying that you are under his or her care for the above diagnosis. That's it. It takes minutes on line and a payment and you are done. The only way fraud here could be eliminated is if licensing authorities cracked down on what constitutes being under someone's care. These certificate mills have licensed "professionals" in each state that will do this over the phone or on line. These regulations may cut down a little bit on the acquisition of these certificates but fundamentally, the requirements are trivially easy to fulfill.