Screening for Fraud, Waste and Abuse Within the Realm of Pediatric Autism

September 23, 2019 HMS

According to the Centers for Disease Control, 1 in 59 children are diagnosed as being on the Autism Spectrum. Applied Behavioral Analysis (ABA) has proven to have a significantly positive effect on improving the lives and capabilities of many people on the Spectrum. As with other effective treatments, ABA and associated therapies for Autism has a cost. In the U.S., the yearly cost of pediatric autism is approximately $66 billion a year. Given the high spend, it is worth exploring whether all of these dollars are going to legitimate providers to ensure that children who need these services are getting the appropriate care and funding.

It is unknown how much of the $66 billion in spending is wasteful or fraudulent, but given the importance of sustaining legitimate programs, certain indicators can provide insights to probe further. These indicators include provider certification, gender and time documentation.

Certifications and Fraud

 While Board Certification for Certified Behavioral Analysts and Certified Assistant Behavioral Analysts do exist for ABA providers, not all ABA therapists require certification to effectively work with children to provide therapies. Regulations are lagging governing what types of therapists or other licensed health care professionals are allowed to provide specific ABA services and utilize particular service codes on their claims.

Florida recently detected a fraud issue when unqualified ABA providers falsely billed for services, resulting in the state ultimately freezing provider payments. Andrew Hourvouras, the president of the Florida Association for Behavior Analysis, voiced concerns about the State’s lack of a sufficient ABA licensure process, which in turn raises concerns about unqualified providers offering (and billing for) services, leaving the door wide open for all kinds of fraudulent activity.

Gender Disparity

The CDC states that males are about four times more likely than girls to receive an autism diagnosis. Out of the approximately 1 in 59 children that are diagnosed, that’s about 1 in 151 girls and 1 in 37 boys.

In general, those numbers should be supported when data is examined for potential fraud. Are investigators finding a disproportionately larger number of girls than boys receiving ABA therapy? Unless a program is specifically targeted for females, if an ABA provider sees a much higher number of girls to boys, it may be a red flag. Therefore, provider cases that are predominantly skewed towards female patients may warrant a deeper exploration of whether there is a legitimate reason that the female patient count is high relative to the male patient count.

It is interesting to note that there is some evidence of girls being handled differently during the initial ABA diagnosis process. While this may eventually result in a need for the medical community to reevaluate its official criteria of diagnosis, current statistics show that boys are still more likely to be diagnosed than girls.

Unreasonable Time Documentation

When reviewing for fraud or waste in ABA therapy, time documentation is an area of focus.

In 2018, this was a factor when the Early Autism Project, South Carolina’s largest children’s ABA provider, paid the United States over $8 million to settle fraud allegations stating that its practitioners submitted false claims to the government. The EAP falsely billed for hourly services that were either not rendered at all or that were significantly padded. In similar cases, evidence of false billing directly contradicted medical notes: according to a 2017 TRICARE report, a 2 year old beneficiary of ABA therapy was actually fast asleep during part of his billed therapy session.

Also, billable hours should be standard given the situation. An indicator of potential fraud is when a practitioner has submitted claims for times when the pediatric patient is in school or, if not actually asleep, participating in another kind of documented activity. It is important to note that ABA therapists often act as “shadows” for children on the Autism Spectrum, so time billed during school hours is not necessarily fraud.

Another point to consider is whether or not the billable hours make logical sense. An example given in HMS’s recent webinar The Healthcare Fraud Horizon: 2019 examines practitioner claims that bill a physically impossible amount, with some claims stating that ABA therapy took place on one day and lasted an astounding 72 hours. This kind of fraud was also found in South Florida’s recent headline grabbing fraud investigation which resulted in subsequent freezing of provider payments. This major incident was first brought to light when the state cracked down on providers who were billing over 24 hours in a single day.

Ultimately, fraud, waste and abuse divert significant resources from government programs designed to assist the millions of children and families whose lives are severely impacted by Autism. Shining a spotlight on these specific areas of fraud is critical to ensure that the millions of children who need ABA and other therapies continue to have available resources.

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