Applied Behavior Analysis (ABA) is commonly used to treat individuals with Autism Spectrum Disorder (ASD). Treatment is designed to improve communication, social skills, and adaptive learning. However, as the prevalence of ASD diagnoses has risen, so has the risk for Fraud, Waste, and Abuse (FWA) and the attention to evaluating the appropriateness of these services has increased. [1]
ABA typically involves a Board Certified Behavior Analyst (BCBA) designing a program that is implemented by Registered Behavior Technicians (RBTs) or Board Certified Assistant Behavior Analysts (BCaBAs). ABA often requires 20 to 40 hours of therapy per week.
What to look for?
Common schemes include billing for services never rendered, inflating the time spent with a patient, unqualified staff, or billing for supervision that did not occur concurrently with the therapy session.
Other potential red flags include:
- Billing for direct therapy (97153) and supervision (97155) by the same provider for multiple patients. These are one-on-one services.
- Billing for technician 97153 without the corresponding supervision 97155.
- Billing for more time than actually rendered.
- Unsupported diagnoses and medical history.
HCFS has you Covered
Combating fraudulent billing in ABA requires a multi-pronged approach. Payors need to leverage advanced data analytics to identify suspicious billing patterns and inappropriate frequencies of service. If you are using the HCFSPlatform™, we’ve got you covered.
Our Artificial Intelligence (AI) models identify spikes, anomalous billing patterns, and “impossible day” scenarios. Some examples of our ABA-specific alerts include:
[2330-07] – INAPPROPRIATE # OF SERVICES PER PATIENT, ABA
[2330-08] – INAPPROPRIATE AGE, ABA
[2330-09] – SUPPORTING DIAGNOSIS MISSING, ABA
[2375-01] – IMPOSSIBLE TIME, ADAPTIVE BEHAVIOR ASSESSMENTS
If you’re not using the HCFSPlatform™ and you’re interested in knowing more, email us at [email protected].
If you have questions or comments, you may email us at [email protected].
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