Navigating the Puzzle Pieces of ABA Reviews
Applied Behavior Analysis (ABA) cases have been a hot topic - even more so since the pandemic. Many plans are finding that these investigations and medical reviews are far more complex than typical FWA cases and require great collaboration among investigators and clinical staff. Download our article to learn the best ways to tackle the ABA cases in your pipeline.
Navigating the Puzzle Pieces of ABA Reviews
What is ABA?
Applied Behavior Analysis, or ABA, is a common and widely used therapeutic approach involving different techniques and methods to modify behavior, particularly for patients on the autism spectrum. Components of ABA can focus on social skills and language, communication, self-care, play, and minimizing problematic behaviors.
Introduction
As we are all too aware, in 2020, for the first time in almost a century, a global pandemic shut down schools, businesses, and day to day activities. There were extraordinary challenges that every business and community faced during this time. But, when you consider vulnerable populations that require certain daily support, the impact of these lockdowns on services was staggering. Though many providers supporting these vulnerable populations operate with integrity and honesty, as you can imagine, the pandemic provided ample opportunities for fraud, waste, and abuse.
One such example involves Applied Behavior Analysis (ABA) services. In the world of fraud, waste, and abuse (FWA), ABA comes under scrutiny for a variety of reasons. At the time this article was written, the Office of Inspector General (OIG) was conducting their own review of ABA claims for “questionable billing patterns” and payments for “unallowable services.” Their findings are anticipated to be released later this year. Various states and health plans have different rules and policies regarding ABA, so it’s equally important to understand the requirements set forth by payers to ensure services being rendered are appropriate.
Provider Expectations
To render ABA services, a provider will often need to submit proof of medical necessity, in the form of a formal assessment, script, diagnosis and/or combination of documentation to support the need for the service. Through the assessment process, a treatment plan is developed, containing specific personal and family information, coordination of care information with schools and other providers, as well as discharge criteria.
Individualized goals are crafted by a Board-Certified Behavior Analyst (BCBA) based on the patient's assessment results, areas for growth and improvement, and behavior related scenarios either observed by the BCBA, or reported by others. A Behavior Intervention Plan can be designed in situations where a behavior interferes with the individual's ability to navigate everyday scenarios.
What to request when doing an ABA review:
Treatment notes for the date(s) of service billed
Patient's current treatment plan
Prior authorization documentation from the health plan
Patient's school-based paperwork (including Individualized Education Plans or IEPs) Any psychological assessments
Medical scripts identifying the recommendation for ABA
Letters from the member’s primary physician
Other pertinent documentation to support medical necessity
In recent reviews of ABA cases, we found two key areas that raised questions about the efficacy of ABA as well as the billing practices of the providers.
Excessive or unnecessary services
Documentation concerns
Let's take a closer look at what to look for during your review.
Concerns with ABA Billing
1. Excessive or Unnecessary Services
Hours billed in excess of what was authorized in the patient's treatment plan
Services not identified in the treatment plan
Example:
Providers billing for group services under CPT code 97154 without indicating the need for group services in the treatment plan or in the authorization documentation.
2. Documentation Concerns
Lack of documentation
Conflicting documentation
Not connecting daily session notes back to the treatment plan
Impossible days and other unusual 'stuff'
Lack of Documentation
Look for:
Missing information when actual behavioral outbursts occur. You may see documentation indicating that a behavior happened, but it fails to account for any details related to the behavior. For example, a child's 'tantrum’ may be documented but what's missing is any antecedents that may have caused the tantrum, indication of severity, duration or intensity of the behavior, information about how a technician intervened or what specific ABA strategies were employed to mitigate the behavior. This makes it unclear how ABA was implemented in moments of outburst.
Missing method of delivery (phone or virtual platform). In scenarios where a virtual platform was used, providers may not document or confirm that the virtual platform was one authorized by the state and/or health plan.
Failure to appropriately document group therapy. CPT guidelines for 97154 indicate this code can be billed for a group of two or more patients, but no more than eight patients. Often, when group sessions are billed, there is no indication of the number of attendees to support the code definition.
Location not noted or incorrect location documented.
Conflicting Documentation
Look for :
Conflicting personal health information (PHI) about a patient, either having the wrong birthdate, wrong age, someone else's name, or a different patient's goals.
Whether the data records a decline in the patient's progress without any modifications from the BCBA. Many treatment plans have a statement indicating that ABA is contraindicated if the child shows a lack of progress. When data points are lower than the patient's score at baseline after six months of treatment or more, the treatment plan should show signs of modifications being made.
Some documents may not contain an agency name or header, some may include other people as present without indicating other 'attendees', some were signed and dated prior to the start of the session.
Check to see if your plan allows 97155 and 97153 to be billed together. Whether or not you are seeing both codes or one code billed, the documentation should align. The use of 97155 is often used in a 'supervisory' role, a requirement of some payers that the BCBA observes and guides technicians on following the treatment plans, adjusting goals and adjusting methods and techniques during treatment. Look to see if BCBA notes indicate the direction of a technician by the BCBA that had contradictory information from what the technician recorded during the same session with regards to goals being attempted, success rate, location, etc.
A note about billing 97155 and 97153 simultaneously.
CPT 97155 is used for a BCBA providing protocol modification. There is conflicting information in the industry around about whether CPT 97155 can be billed simultaneously with CPT 97153, which is the code allowing technicians to provide direct care to a patient. In some instances, payers may only allow one of the codes to be billed. However, through a number of other references, we found no indication that 97155 cannot be billed with 97153 simultaneously unless the BCBA is providing care directly without a technician present. However, when the technician provides the direct care to the patient, and the BCBA observes and makes recommendations to the technician during the session, billing both codes simultaneously may be acceptable.
Connecting the dots with treatment plans.
Treatment plans are personalized to all related aspects of the patient's care during a timeframe and are typically written for a period of approximately six months. This is a living, changing document that evolves through the course of treatment. The initial plan is usually provided to the payer as part of the request or authorization for services. During the course of treatment, BCBAs observe the patient, read recorded data, meet with parents, teachers, and other professionals, and directly interact with the patient. As the patient meets or does not meet expectations, the BCBA may modify goals in the middle of a treatment timeframe or as frequently as needed. More often than not, providers send in the initial authorized plan, which does not reflect the many goal updates and changes that occur throughout treatment. As such, connecting the dots becomes challenging, as a reviewer may be unable to link daily session notes back to a specific goal in the treatment plan.
Impossible days and other unusual 'stuff.'
Look for:
Services billed in excess of what's typically allowable or reasonable in a day.
Back to back sessions in different locations billed without a break in time to account for travel.
Members billed over the number of hours requested in the individual member's treatment plans.
Dates of service billed for unusual times, such as services provided at 1 am.
Moving Forward.
Once you've identified improper billing, prepayment review may be the best option for stopping this behavior from continuing. While some organizations have strong prepayment practices, others may not. So there are some things to consider if you decide to use prepayment review as a preventative measure to stop further improper billing.
If you decide to put a provider prepayment claim review:
Have policies related to ABA handy including health plan, state and federal policies. Use AMA CPT and other professional organization sites pertaining to ethics, billing, and documentation expectations.
Discuss discrepancies, concerns and billing aberrancies as well as your conditions of payment with a medical director (preferably a behavioral health provider) if you have one. It's important to make sure that decisions you make are in line with your plan policies and will be backed by your internal leaders.
Expect additional documentation to show up. Providers will appeal and provide 'more' information via addendums or data sheets that may not have been originally included. Sometimes this only raises more questions because what's written in the anecdotal notes might be too brief to quantify time billed and doesn't always align with the treatment plan.
Don't forget to ask for the most updated version of the treatment plan. Many providers might only send in the 'original' treatment plan even though through the course of treatment, goals changed for the patient.
Wrap-Up
The need for investigation into questionable ABA billing practices is crucial to ensure the most vulnerable populations receive the care they need. Documentation must accurately reflect all pertinent information to support the services being rendered. When documentation has gaps in information, lacks data to quantify the time billed, contains discrepancies between the session data and treatment plan, or any of the concerns we've discussed in this article, take a deeper look.
Need help with ABA investigations and reviews?
That's what we're here for. Integrity Advantage is the way healthcare payers reimagine the value of their fraud, waste and abuse program. Our experience providing consulting, investigative, medical review and training support to plans across the country gives our clients a tremendous advantage. We take our role as a trusted advisor very seriously, providing objective perspectives and offering solutions for real challenges faced by the healthcare payment integrity industry.
Integrity Advantage is the way healthcare payers reimagine the value of their fraud, waste and abuse program. We provide FWA services to payers around the country.
If you need a program assessment, program growth strategy, investigations, medical reviews or training support -- reach out today.
We are a certified Women’s Business Enterprise (WBE) and an Economically Disadvantaged Woman Owned Small Business (EDWOSB).
For more information click below, call us at 866-644-7799 or email info@integrityadvantage.com.