Mitigating Fraud, Waste and Abuse in ABA for Health Plans

By: Dana D’Ambrosio, MS, BCBA, LBA
Published: Feb 23, 2023
Medical papers, calculator and stethoscope on table

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

RethinkFutures Solutions to Help Prevent Fraud, Waste and Abuse

RethinkFutures’ clinical decision support solution utilizes an evidence-based approach, including an objective, individualized recommendation for 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, RethinkFutures’ clinical decision support can provide reassurance while streamlining the review process.

Learn more about our Platform.

How RethinkFutures Partners with Payors

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

RethinkFutures platform leverages millions of data points, modern data science, and clinical expertise to help payors optimize care at the individual level and across their ASD provider networks.

About the Author

Headshot of Dana D’Ambrosio, MS, BCBA, LBA, Clinical Development for RethinkFutures

Clinical Development

Dana D’Ambrosio leads Clinical Development for RethinkFutures. She is a New York state licensed and Board-Certified Behavior Analyst. She brings over a decade of clinical knowledge, with experience spanning from direct patient care in various treatment settings to utilization and care management within the payor realm. She specializes in the creation and enhancement of technology solutions utilized by providers and health plans, to ensure best practice, high quality, coordinated care and streamlined review processes for all parties. She received a BS from the University of Central Florida and an MS degree in Counseling, specializing in Applied Behavior Analysis, from Nova Southeastern University.

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