FWA Insights: Catching inappropriate billing within ASD services

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.

What is adaptive behavioral therapy?

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:

• A provider of autism services was accused of having billed ABA services to individual children when the services were being provided to groups
• A person posing as a qualified practitioner caused Medicaid to pay out on more than 1,900 fraudulent claims related to children with ASD
• A provider of autism services paid more than $2.7 million over TRICARE claims related to ABA services that could not be verified

The discovery: Identifying an excess of ABA services per patient

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:

• CPT 97153: Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes
• CPT 97155: Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes

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:

• Documentation didn’t include specific protocol modifications in the session to support the codes billed 
• Documentation didn’t support supervision per the code requirements
• Documentation did not support the code billed, as the intervention performed was not present in the patient's care plan
• Documentation did not include progress to goals
• Informed consent was not present in the records
• Missing or invalid dates were noted in the records

Lessons learned: Savings and prevented loss totaling $250,000

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:

• Determine if the individual performing the service is qualified to perform the service and that the appropriate supervision is documented
• Determine if an appropriate number of units per code were billed by the provider for services rendered
• Revisit policies and editing capabilities to determine whether updates are needed based on overutilization by providers
• Maintain close collaboration between health plan payment integrity and SIU stakeholders to successfully avoid long-term losses to potential FWA