Mitigating Fraud, Waste and Abuse in ABA for Health Plans

By: RethinkBH Team

Medical papers, calculator and stethoscope on table

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There is increasing attention on the appropriate provision of behavioral health services. With the rise in Autism diagnoses to 1:44 children, it is critical to consider the inevitable upsurge in fraud, waste, and abuse for Applied Behavior Analysis services. The global market for ABA therapy was estimated at $2 billion in 2020 and is expected to grow at 4% per year to reach $2.45 billion by 2025. Given these numbers, the potential for monetary losses is substantial and will ultimately affect the quality of care.

A single search through the website of the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG) shows a litany of cases with recoupment and litigation. While not all instances of fraud, waste, and abuse (FWA) will conclude in this fashion, the ability to prevent the potential on the front end is paramount.

Examples Of Fraud, Waste and Abuse in ABA

Some of the more common examples, which can be prevented during the review of treatment plans, include:

  • Failure to maintain adequate medical and financial records
  • Submission of claims for services that are not medically necessary and/or for services that did not actually occur (such as requesting 40 hours/week when a family’s schedule allows for 10)
  • Misrepresentation of services
  • Up-coding: Billing for services at a higher level than provided or necessary
  • Concurrent billing of CPT codes when not permitted

Technology to Help Manage Instances of Misuse

There is a growing trend towards the use of technology in healthcare, and this includes ABA therapy. Technology can be used to help manage instances of fraud, waste, and abuse and improve patient care.

It is essential that any instances of misuse are identified and addressed as soon as possible, ideally prior to affecting patient care. Methods of prevention include:

  • Use of electronic health records (EHRs) to track patient information and services provided
  • Objectively determining medical necessity
  • Verification that evidence-based treatment approaches are utilized
  • Monitoring appropriate dosage of ABA therapy
  • Systematic and analytic review to ensure submission of complete medical record
  • Consistent application of benefits

Rethink Care Management’s Solutions to Help Prevent Fraud, Waste and Abuse

Rethink’s Medical Necessity Assessment (MNA), is a tool that utilizes an evidence-based treatment approach, including an objective but an individualized recommendation for appropriate dosage of ABA therapy.

The tool was created to

  • advocate for individuals in need of ABA services
  • ensure patients with Autism are receiving the appropriate levels of care
  • optimize outcomes by demonstrating clinical standards are met

The tool provides

  • standardized methods to document information received from providers
  • quantified responsivity to treatment
  • a clinical decision-making model determine the medical necessity for ABA services
  • consistent application of benefits to ensure the appropriate amount of services are being authorized
  • support that quality of care is being demonstrated
  • resolution to communication barriers between many providers and payors

As a payor, concerned about fraud, waste, or abuse in the ABA therapy industry, the MNA tool can provide reassurance while streamlining the review process.

Learn more about this tool.

How Rethink Care Management Partners with Payors

Rethink Care Management is part of Rethink First, a global health technology company providing cloud-based treatment tools, training, and clinical supports for individuals with developmental disabilities and their caregivers.

The need on the payor side for validating that medical necessity criteria are being met when treatment plans are being submitted by providers is complex. As such, Rethink has expanded its platform to develop tools for care managers, which includes the above-mentioned Medical Necessity Assessment and the Clinical Progress Tracker, among other supports for Member Engagement. To learn more about the solutions, contact us.

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