With the growing popularity of Behavioral Analysis comes even greater responsibility. If you’re an ABA provider working with insurance carriers, you’ll likely go through multiple audits in the course of your business. Auditing for ABA practices is no longer a probability but a certainty.
Understandably, an audit from payers can be intimidating. That is particularly true for small ABA practices without the technology or manpower to handle big claims. Receiving an audit notification coupled with the audit process is, therefore, overwhelming. And the thought of potential consequences only makes it worse.
While daunting, health insurance audits don’t have to be challenging. You only need to implement proper strategies.
Below is an overview of basic preparations to keep your ABA practice audit-ready.
When are ABA Providers Audited?
As mentioned, auditing is no longer a question of “if” but “when.”
Often, there is no discernable cause for the health insurance audit. Neither do payers disclose the “why” behind an audit. (After all, the element of surprise is an essential part of the process.)
However, there are specific circumstances that can warrant an audit. Think of:
- Outlier payments
- Higher-than-average utilization rate
- Billing a new procedure
- Complaints from employees or patients
- More use of specific codes than peers in the same geographical area
- Previous errors or problems (past fraud claim)
- Random selection
(Remember, to a payer, auditing is a strategic way of rooting out fraud, waste, and abuse in the healthcare system. Theirs is to ensure proper management of claims and operations.)
The bottom line, you can get audited anytime, for no apparent reason. So rather than putting your head down with your fingers crossed, why not prepare and get audit-ready?
What are the Professional & Ethical Compliance Standards for BCBAs?
While an audit help payers root out fraud, it’s also an excellent opportunity for you to foster proper billing practices and compliance.
When practicing, you’ll need a staff handbook detailing employee expectations and guidelines to follow. It should indicate job descriptions, staff responsibilities, training requirements, staffing background requirements, and more.
(Your responsibility to your staff includes annual OSHA and HIPAA training and ensuring they meet all the BACB board and state provisions for delivering ABA therapy.) Be sure to include direct services, therapy sessions, supervision sessions, parent training, assessments, and other relevant data.
You’ll also need a client handbook detailing the families’ do’s and don’ts during service. For example, your sick policies should clearly state under what circumstances parents can cancel an appointment in light of the kid falling ill. They should also detail who the family should contact to divulge the information.
The family handbook should also outline what clients (patients) can expect from your practice. For example, you must report anyone identified as neglecting the child (patient). So make that clear to parents. It should also detail how families can file a complaint alongside HIPAA consent forms, crisis policies, emergency policies, and more.
(Overall, you should review HIPAA/OSHA laws and policies and ensure your practice stays up-to-date.)
When getting audit-ready, there are professional and ethical compliance standards for BCBAs that hit closer to home. Think of:
- Take reasonable measures to protect the confidentiality of your patients
- Discuss confidentiality at the outset of your relationship with the patient, and as emerging issues warrant
- Only document the patient’s information that’s relevant to the treatment
- Only discuss and analyze patient’s confidential information for scientific or professional purposes only.
- Don’t share or create circumstances that’ll warrant the identification of your supervisees and clients within social media.
- Maintain confidentiality in creating, accessing, storing, sending, and disposing of client records
- Maintain and dispose of patient records as per applicable policies, laws, and regulations
- Only disclose client’s confidential information with their consent, except where allowed by law for eligible reasons, such as:
- Providing required services to patient
- Obtaining relevant professional consultation
- Protecting the patient from harm
- Obtaining payment for services that require full disclosure
- Accurately state the nature of therapy provided. Include charges, relevant outcomes, and other relevant descriptive data.
Consent for Client Records
- Get client consent before obtaining or disclosing their records.
Access the entire professional and ethical compliance for BACBs code here.
Probable Non-compliance Consequences
The impact of a health insurance audit can vary – from an insignificant inconvenience to a substantial disruption. While not as painful as an IRS audit, a health insurance audit can lead to:
- Contract termination
- Repayment review
- Reimbursement to pay back non-compliant claims
- Probable fraud investigation
- Financial loss
- Business loss
- Ruined company reputation
7 Non-Compliance Issues ABA Providers Should Fix
As noted, auditing is no longer a probability but a certainty. However, certain red flags make auditing a frequent occurrence. While some risks are ineradicable, you can fix major issues and get audit-ready.
Here are some non-compliance issues you should fix.
Issue 1: Inadequate Documentation
Payers need to verify medical necessity, which calls for an accurate and consistent document. You must have adequate assessments and treatment documentation that proves that:
- Services were provided
- Services were delivered at the level they’re billed
- Services provided were necessary
A lack of adequate and consistent documentation is prone to questioning, as payers cannot verify billing.
Solution: Unlimited Document Storage
AccuPoint 2.0 lets you store all your session notes, intake forms, and other relevant documents in a secure and easily accessible location. The platform also provides customizable assessment forms for easy implementation of standard treatment protocols and checklists.
Better still, the software provides reminders (text and email alerts) to file a patient report if you haven’t already.
Issue 2: Billing Irregularities
Payers love billing consistency. As such, fluctuating billing rates are bound to attract scrutiny. That creates a need for standard fees schedules in addition to accurate and organized billing information.
Solution: Billing Optimized for ABA Practices
AccuPoint 2.0 provides fee schedules that ensure billing consistency while calculating payments. It also ensures accurate client ledgers by tracking and sharing your insurance billing remittances to client’s accounts.
Issue 3: Outliers From the Industry Norm
Payers often compare your practice with similar providers in your geographical area. Thus, any significant deviation from the ABA industry standard is prone to scrutiny. For example, if you’re billing 40 hours a week and ABA therapists usually work 20 hours a week, payers may request validation.
Solution: Reporting & Analytics
AccuPoint 2.0 billing software does more than submit claims. You can access tools that provide daily reports to help validate any deviations from the norm. The software also boasts a comprehensive data export feature for easy auditing.
Better still, the reporting feature:
- Provide insights into your practice financials
- Track growth, and
- Help identify gaps
Issue 4: Outdated Credentials
When states and insurance carriers change certification requirements, you’re expected to adapt accordingly. Consequently, continued practice with outdated credentials is prone to revoked or denied payments.
Solution: Robust Billing Software
AccuPoint 2.0 keeps you up-to-date with developments in the ABA industry. That eliminates the risk of lagging and its consequences.
Issue 5: Erroneous Billing Codes
While a human is to err, some errors look suspicious to payers. For example, when you use multiple CPT codes for different parts of therapy treatment, payers are bound to raise questions. After all, they’re unsure whether you lack a clear understanding of billing practices or just trying to increase payments.
Solution: Practice Management Software
AccuPoint 2.0 practice management software helps remove common mistakes by linking claims, authorizations, and scheduling to Clinical Notes templates.
Issue 6: HIPAA Violations
HIPAA violations are sure to prompt an audit. They could be less obvious: non-encrypted video calls. Or obvious mistakes like crashing hard drives. Common HIPAA violations include:
- Sending PHI in unsecured emails
- Texting PHI
- Throwing PHI documents in the bin
- Using EMR systems that aren’t compliant
- Improper transportation of clinical documentation
- Using vendors who violate HIPAA
As noted, you should store client documents in a well-organized location that’s inaccessible by unauthorized staff.
Solution: HIPAA-Compliant Document Management
Protecting documentsis a vital responsibility, especially with the increasing risk of data breaches. AccuPoint 2.0 provides a HIPAA-compliant system that manages every aspect of your practice. The software helps with document management, tracking authorizations, and permission-based scheduling.
With AccuPoint 2.0, you get to create authorizations, assign ABA treatment types, record the maximum allowed duration, and get notified when they are about to expire.
Issue 7: Claim Errors
Insurance claims with incorrect client and billing information barely escape a payer’s radar. Yet, combing for inaccuracies and other common errors is time-intensive. Well, unless you deploy the right software.
Solution: Get Expert Help
Partnering with AccuPoint help turn your weaknesses into bulletproof audit readiness. Our insurance billing experts can take over the billing process with precision. By handling everything from claim generation to follow-up, we take over the time-intensive counterchecking activity – freeing you more time to focus on your business.
We leverage our experience and expertise to reduce billing inefficiencies and errors that delay payment. We also investigate claim denials and resolve the issue promptly.
Get Audit-Ready with AccuPoint
Seeing that auditing is a guaranteed occurrence, the focus then shifts to getting ready. As highlighted, risks such as HIPAA violations and erroneous billing codes can prompt an audit. As such, you must ensure consistency and accuracy in all areas of your ABA practice. AccuPoint steps in to do exactly that. From providing unlimited document storage to equipping your system with a HIPAA-compliant system, AccuPoint is the ABA partner you’ve been searching for.
Larger practices can Schedule a demo to see firsthand how this software can help keep your practice audit-ready while solo practitioners and smaller practices can try AccuPoint 2.0’s software free for 21 days.