Wisconsin improperly paid at least $18.5 million in fee-for-service Medicaid payments for applied behavior analysis (ABA) services for children with autism.
According to a new report from the Office of the Inspector General, the state’s Medicaid payments for ABA services did not fully comply with federal and state requirements.
This report comes as the federal government has pledged to crack down on fraud, waste and abuse in health care.
According to the report, the primary cause of improper payments was session notes that didn’t support the billed CPT codes. The second most significant reason for improper payments was that session notes didn’t support the number of units billed.
The report goes on to say that it estimates potentially improper payments could amount to around $94.3 million, with $62.3 million of that from the federal share.
The most common reason for potentially improper payments was that session notes did not contain complete descriptions of the services provided.
The OIG recommended that Wisconsin refund the federal government the amount of the improper payment, approximately $12.2 million. Additionally, the agency recommends that “Wisconsin Department of Health and Human Services “exercise reasonable diligence to review and determine whether any of the estimated $62,334,835 (Federal share) in potentially improper ABA payments complied with Federal and State requirements and refund the Federal share of any improper payment amount to the Federal Government.”
In the future, the OIG also recommends that the state provide ABA providers with more guidance about the proper way to document services. It also suggests that the state develop a procedure to verify providers and their specialty level. Additionally, Wisconsin should conduct periodic statewide reviews of Medicaid ABA payments, according to the recommendations.
