HMA Spotlight
ABA Compliance and Strategic Policy Support for Medicaid Managed Care Organizations
Applied Behavior Analysis (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 fraud, waste, and abuse (FWA) concerns. To optimize quality care for members, MCOs who cover these services must have policies regarding ABA benefit structure, clinical guidelines, utilization management, and service delivery. Plans also need to monitor for and identify possible FWA concerning documentation and/or billing practices for these services. MCOs with comprehensive ABA compliance and auditing programs can meet these critical needs.
Our team
HMA’s national presence keeps us at the forefront of ABA-related changes in multiple states. HMA’s team of behavioral health clinicians have years of experience conducting FWA audits and have specific training required to conduct detailed and meticulous ABA reviews. Our team includes operational and clinical subject-matter experts with board certifications in behavior analysis (BCBA, RBT) who can support auditing activities as well as policy review and revision. We will work with your organization’s team to provide the insights necessary to maximize ABA quality of care and cost efficiency.
How HMA can help
We work closely with MCOs to develop a customized scope of services that meet their unique ABA compliance, policy, and strategy needs.
We can help MCOs with:
- Establishing their own ABA compliance programs
- Conducting audits of ABA provider claims and associated medical records, using customized audit tools and findings reports, to identify potential FWA, including as part of an MCO’s Special Investigation Unit (SIU) program
- Reviewing and providing feedback on ABA-related policies
- Developing ABA-related documentation forms
- Providing consultation on ABA reimbursement/utilization benchmark development
- Providing support in building cohesion/collaboration between MCO and local Department of Developmental Disabilities representatives
- Developing strategies to improve care coordination for youth transitioning to adulthood
- Assisting MCOs with their Managed Behavioral Healthcare Organizations (MBHO) benefit oversight
- Demonstrating how to maximize the interface of organizational Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Medicaid benefits and the intersection with ABA services
We produce results
Our auditing team members have supported the SIUs of three Medicaid health plans in different states. We have demonstrated a 12:1 return on investment for our clients, based on associated recoupment of improper payments and estimated prevented loss.
If you have questions about our ABA compliance, policy, or strategic support services, contact our experts below.
Contact our experts:
