View all case studies
THE CLIENT
HMA’s team of expert behavioral health auditors from Crestline Advisors performs audits of behavioral health services, including applied behavior analysis (ABA) services, for a Medicaid health plan in Virginia (“the client”). The client refers cases to HMA when there are allegations of possible fraud, waste, or abuse (FWA) concerning documentation and/or billing practices for these services.
BACKGROUND
ABA is an evidence-based behavior therapy for people with autism spectrum disorder (ASD) and other developmental disorders. In recent years, the diagnosis of ASD and subsequent demand for ABA services has increased. State Medicaid administrations and Managed Care Organizations (MCOs) are tracking increased ABA utilization and wait times for these services, and in some situations are investigating quality of care and/or FWA concerns. Types of FWA concerning ABA therapy services may include billing for services not rendered, billing for ABA services without documentation of ABA-specific interventions, billing for services by unqualified individuals, or billing more units than the documentation supports, to name a few. We have a deep bench of licensed behavioral health clinicians and coders with many years of experience in conducting audits for MCOs, state Medicaid administrations, and providers. Given our expertise, we understand the importance of the golden thread of documentation that should underlie billing, including assessments and treatment plans which identify the need for ABA services and documentation of ABA service interventions, supervision, and family training.
APPROACH
The client’s SIU team identifies providers of ABA services for whom there is an allegation of potential FWA and provides us with sample claims and medical records to review. We have developed customized audit tools to investigate the unique documentation and billing considerations for ABA. Incorporating state-specific provider/billing manual requirements, we conduct pre- and post-pay audits in which we may identify errors in documentation (misalignment with what is billed on the claim). We then provide a detailed report to the client summarizing the identified errors and potential improper payments. Our team also can assist in the pre-audit phase to develop provider communications to request medical records and provides post-audit support to MCOs to help explain findings to providers impacted by the audit, or to support the MCO in an appeal or fair hearing process.
RESULTS
This is an ongoing project that has already provided significant value to our client in a short period of time. The client’s analysis of our auditing work, which included ABA findings reports as well as findings reports for other behavioral health services, has already identified a 12:1 return on investment, based on associated recoupment of improper payments and estimated prevented loss. Our own internal ROI analysis, focused specifically on ABA audits, also identified a 12:1 benefit. By working with our team, MCOs can expect to see timely and thorough identification of potential improper payments upon which they may act to reduce FWA. Ultimately, reducing FWA leads to increased availability of services for the members who need them most and promotes improved quality of care from qualified professionals. To learn more, email Shannon Walters.
THE CLIENT
HMA’s team of expert behavioral health auditors from Crestline Advisors performs audits of behavioral health services, including applied behavior analysis (ABA) services, for a Medicaid health plan in Virginia (“the client”). The client refers cases to HMA when there are allegations of possible fraud, waste, or abuse (FWA) concerning documentation and/or billing practices for these services.
BACKGROUND
ABA is an evidence-based behavior therapy for people with autism spectrum disorder (ASD) and other developmental disorders. In recent years, the diagnosis of ASD and subsequent demand for ABA services has increased. State Medicaid administrations and Managed Care Organizations (MCOs) are tracking increased ABA utilization and wait times for these services, and in some situations are investigating quality of care and/or FWA concerns. Types of FWA concerning ABA therapy services may include billing for services not rendered, billing for ABA services without documentation of ABA-specific interventions, billing for services by unqualified individuals, or billing more units than the documentation supports, to name a few. We have a deep bench of licensed behavioral health clinicians and coders with many years of experience in conducting audits for MCOs, state Medicaid administrations, and providers. Given our expertise, we understand the importance of the golden thread of documentation that should underlie billing, including assessments and treatment plans which identify the need for ABA services and documentation of ABA service interventions, supervision, and family training.
APPROACH
The client’s SIU team identifies providers of ABA services for whom there is an allegation of potential FWA and provides us with sample claims and medical records to review. We have developed customized audit tools to investigate the unique documentation and billing considerations for ABA. Incorporating state-specific provider/billing manual requirements, we conduct pre- and post-pay audits in which we may identify errors in documentation (misalignment with what is billed on the claim). We then provide a detailed report to the client summarizing the identified errors and potential improper payments. Our team also can assist in the pre-audit phase to develop provider communications to request medical records and provides post-audit support to MCOs to help explain findings to providers impacted by the audit, or to support the MCO in an appeal or fair hearing process.
RESULTS
This is an ongoing project that has already provided significant value to our client in a short period of time. The client’s analysis of our auditing work, which included ABA findings reports as well as findings reports for other behavioral health services, has already identified a 12:1 return on investment, based on associated recoupment of improper payments and estimated prevented loss. Our own internal ROI analysis, focused specifically on ABA audits, also identified a 12:1 benefit. By working with our team, MCOs can expect to see timely and thorough identification of potential improper payments upon which they may act to reduce FWA. Ultimately, reducing FWA leads to increased availability of services for the members who need them most and promotes improved quality of care from qualified professionals. To learn more, email Shannon Walters.
Download
