Last month, Massachusetts became the first state to require applied behavioral analysis (ABA) providers to become accredited.
The Massachusetts Executive Office of Health and Human Services adopted the new rule in October after the Massachusetts attorney general and inspector general questioned the level of quality control at ABA clinics in the past year.
Providers who use ABA to treat patients diagnosed with autism spectrum disorder say they are on board with the accreditation requirement in Massachusetts and are hungry for further standards that level the playing field.
“Accreditation doesn’t guarantee business success,” Cathy Lopez, chief operating officer at Cortica, told Autism Business News. “But it does show existing and new teammates, our patients, and their families that Cortica takes its clinical quality and administrative processes seriously and can withstand the scrutiny of an external audit.”
In seeking accreditation, providers have two choices: the Autism Commission on Quality and the Behavioral Health Center of Excellence, which are each part of larger organizations. The state of Massachusetts has indicated no preference for either accrediting organization.
The arrival of two accreditors, neither of which existed a decade ago, highlights how fast ABA therapy has grown. It also shows how providers, payers and regulators are still reckoning with standardizing an immature industry.
The Massachusetts mandate
Last year, Massachusetts Attorney General Andrea Joy Campbell reached an over $2.5 million settlement with two ABA providers over allegations of fraudulent overbilling MassHealth, the state’s Medicaid program. In announcing the settlement, Campbell raised the issue of standards, particularly in light of the federal government clarifying a decade earlier that providers who treat children with autism could bill Medicaid.
“The defendants involved in these two settlements not only failed to comply with the necessary standards for providing critical services to a vulnerable population with autism spectrum disorder, but also fraudulently exploited public funds,” Campbell stated at the time.
Then, earlier this year, Massachusetts Inspector General Jeffrey Shapiro released a report finding that managed care entities contracted with MassHealth, “did not employ robust program integrity measures to ensure that children on MassHealth received properly supervised treatment.”
Massachusetts Health and Human Services responded in October with a requirement that ABA providers who bill MassHealth must receive an outside accreditation by the start of 2027. By 2028, all Bay State ABA providers must have accreditation.
“Requiring accreditation by a nationally recognized accreditation body specializing in ABA provides an additional level of accountability and oversight to help ensure MassHealth members receive high-quality care,” a MassHealth spokesperson told ABN.
Massachusetts’ mandate is a sharp turn from prior rules guiding ABA.
“State agencies do not usually have a large standard set for ABA care,” said Jenna Kokoski, vice president of clinical strategies at Jade Health, the parent company of the Behavioral Health Center of Excellence. “It is often comprised of clinician qualifications and clinical documentation standards.”
Kokwoski told ABN that states do require individual clinicians to be certified behavioral analysts, a role played by the Behavior Analyst Certification Board, a nonprofit based in Littleton, Colorado.
Otherwise, states may stipulate little more than compliance with broader health care laws such as the Health Insurance Portability and Accountability Act (HIPAA), Kokoski said.
The rigor of accreditation
Jade Health was developed to be the parent organization of the Behavioral Health Center of Excellence (BHCOE), a Los Angeles-based company that started in 2015 to provide accreditation to ABA providers.
The revamped structure, Kokoski said, reflects that BHCOE is one part of Jade Health, which also consults providers.
Kokoski noted that BHCOE standards are made by an outside commission and not Jade Health employees. They are also subject to a public comment period. BHCOE is itself accredited by the American National Standards Institute, a body that gives seals of approval for accreditors in many industries.
Kokoksi described BHCOE’s accreditation process as labor intensive. Providers must go through a “documentation phase that shows all the right policies and procedures are in place, including for billing.”
Indeed, BHCOE accreditation demands everything from providers developing a diversity statement to procedures on reporting suspected misconduct. Also, each clinic, rather than a whole organization, must reapply for accreditation every two years.
ACQ, meanwhile, was launched in 2022 in Louisville, Kentucky, by the Council of Autism Service Providers, a nonprofit trade group that itself was founded in 2015.
As with BHCOE, the ACQ standards appear comprehensive. They run 75 pages long and include matters like how to delegate duties and ethical marketing practices.
“Alignment with ACQ’s standards implies a focus on clinical outcomes, patient safety, and compliance with applicable regulations,” said Erick Dubuque, director of ACQ.
BHCOE has accredited approximately 1,500 clinics, Kokoski said, including clinics run by Cortica, a San Diego-based multispecialty autism therapy services provider that is expanding across the country.
Lopez, Cortica’s chief operating officer, described BHCOE accreditation as a major undertaking that “required significant cross-functional team collaboration.”
“We had all the key components in place for accreditation,” Lopez said. “Our challenge was to organize them in the framework BHCOE provided.”
Accreditation’s future
According to Kokoski, a handful of states in the Northeast and West Coast are mulling stronger standards for ABA providers, but no state appears poised to join Massachusetts anytime soon.
In other words, in everywhere besides Massachusetts, the costly, time-consuming task of accreditation is optional. Nonetheless, providers interviewed say it is part of running a business that is legitimate in the eyes of health insurance companies and patients.
“It allows a family to begin building a list of providers,” said Krista Boe, chief clinical officer at Acorn Health, a national autism therapy provider headquartered in Coral Gables, Florida.
Boe noted that sectors from hospital systems to restaurants seek accreditations, calling it the mark of a maturing industry. Acorn Health’s clinics are accredited by BHCOE. and are in the process of ACQ accreditation, Boe said.
Lopez said that Cortica viewed accreditation as “table stakes.”
“It reflects a certain level of quality standards,” Lopez said.
Boe also said that the use of independent accreditors can show providers are serious about policing themselves, as formal state regulations have yet to catch up.
“I don’t think I’m alone in believing we’re under-regulated,” Boe said. “But I don’t have a strong opinion on whether rules should come from states or an independent accrediting body.”
Editor’s note (Nov. 12, 2024): This article was updated to correct Jenna Kokoski’s name. It also now correctly describes Jade Health and Behavioral Center of Excellence as companies, not nonprofits.
