State Medicaid programs are federally required to cover applied behavior analysis (ABA) services for children with autism. In 2020, the state of Indiana’s fee-for-service Medicaid payments totaled $101.8 million, the second highest in the U.S.
An audit completed by the Office of Inspector General (OIG) for the United States Department of Health and Human Services (HHS) revealed that Indiana improperly paid out an estimated $56 million for ABA services, $39.4 million of which was billed to Federal Medicaid. The state paid a further $76.7 million in “potentially” improper ABA payments, $53.2 million of which fell to the Federal government.
The findings could result in increased supervision of ABA providers in the state. The issues discovered by the OIG could also impact the quality of care, according to the audit.
“The State agency made improper and potentially improper payments because it did not provide effective oversight of [fee-for-service] Medicaid ABA payments. Specifically, the State agency did not provide sufficient guidance to ABA facilities for documenting ABA,” the report read. “The issues that led to potentially improper payments could have had a significant effect on the quality of care provided to children with autism.”
Specifically, the OIG analyzed Indiana Medicaid’s fee-for-service payments from January 2019 to December 2020, which totaled $151.1 million, $104.5 million of which was the Federal share. A random sample of 100 enrollee-months included bills from 41 unique ABA facilities and 96 unique enrollees. This sample included payments totaling $967,294.
For 97 of the 100 sampled enrollee months, Indiana Medicaid paid $433,472 for at least one claim line that did not comply with state and Federal guidelines.
The discovered billing deficiencies included session notes that did not meet documentation requirements, services provided by staff without appropriate credentials and services rendered to children who did not receive required diagnostic evaluations or treatment referrals.
The audit also uncovered “potentially improper” ABA payments amounting to an estimated $76.7 million. Problems with documentation for these payments include that session notes did not fully disclose the extent of services, that session notes included time spent on meals, breaks, naps and other nontherapy time and that session notes included recreational or academic activities that do not count as allowable ABA activities.
Based on the audit findings, the OIG recommended that Indiana refund $39.4 million to the federal government. It also recommended that the state give ABA providers more guidance on ABA documentation and periodically perform a post-payment review of Medicaid ABA payments.
