Over the past several decades, significant improvements have been made in diagnosing and treating those with autism spectrum disorder (ASD). In a study conducted in 2018, one in 44 children eight years of age was estimated to have ASD, a dramatic increase compared to a 2000 estimate of one child in 150. While resources for those with autism continue to grow, so does the opportunity for bad actors to exploit a vulnerable population.
In this fifth installment of our Cotiviti FWA Insights blog series, we’ll explore how services specific to those with ASD are being manipulated for undue reimbursement, focusing on a case involving inappropriate billing for applied behavior analysis.
Applied behavior analysis (ABA), which is also known as adaptive behavioral therapy (ABT), is a discipline that focuses on analyzing, designing, implementing, and evaluating social and environmental changes to affect human behavior. An ABA session usually involves the provider working one-on-one with a patient to improve language and communication skills and decrease negative behaviors. The specific exercises for the session vary from provider to provider and patient to patient.
While ABA is primarily used with those diagnosed with ASD, it can also be used to treat other conditions and developmental disorders like substance abuse or dementia. Services are typically provided by licensed Board-Certified Behavior Analysts (BCBA), but depending on the health plan, they can also be billed by social workers and early intervention specialists.
However, bad actors have been known to abuse ABA codes for undue reimbursement, billing for appointments that never took place or inflating appointment hours, such as in these examples:
In a Cotiviti audit, a Cotiviti investigator identified a provider billing an excessive number of ABA services units per patient as they related to two specific CPT codes:
The provider also billed a suspiciously high number of timed procedures per day, including several claims where they billed for 32 units (8 hours) of ABA for a single patient on a single date of service (DOS)—an outlier from peers who bill an average of 2–4 units (30–60 minutes) per DOS. These services are most typically billed for an hour duration, but can also reasonably be billed for up to four hours. Anything more than four hours per patient per DOS would generally be flagged as suspicious and subjected to further review.
In this case, the provider billed for five hours or more of time with the patient per visit. Upon additional review, the investigator identified 25 DOS on which the provider billed for services that would take more than 24 hours or more to render, a scenario often referred to as “impossible days.” The investigator found 249 additional DOS that would take more than 8 hours to render.
Cotiviti’s medical review team completed an initial medical record review and identified an overall error rate of 100% due to insufficient and/or missing documentation, including evidence that:
A subset of these claim decisions were appealed and all of the claim decisions were upheld. The appeal review identified additional potential fraud issues including altered psychological reports, altered plans of care, amended notes, and other documentation that did not clearly identify the changes made to the documents. The audit resulted in total savings of approximately $250,000.
For health plans that regularly process ASD-related claims, keeping an eye on FWA within ABA services is key. To be proactive, consider a few takeaways:
Whether you’re looking for support or an entire outsourced team, Cotiviti’s SIU can help your plan to stop FWA in its tracks. Cotiviti’s FWA solutions provide an end-to-end process for flagging, investigating, and preventing FWA within claims. Claim Pattern Review is a prepay solution that catches suspect patterns early, maximizing returns by preventing erroneous or wasteful claims payment. And FWA Management covers the latest in fraud detection and compliance for a robust solution that keeps your organization current and safeguarded against the latest schemes. Read our fact sheets to learn more.