You may have come across the recent Wall Street Journal investigative articles about compliance issues in ABA Medicaid programs. Some of the information included was indeed shocking, including reports of a provider who received $340,000 per child receiving services. If you were shocked and appalled, you should be. We are, too. Waste, fraud, and abuse in ABA services is unacceptable and jeopardizes access to services for those children who benefit from them.

 

I wanted to take this opportunity to share some of the measures that TRICARE has put into place to minimize the likelihood of such abuses in its system.

• There are set rates for all services, based on the service, the provider's credentials, and the service location. While this does not necessarily prevent a provider from providing incorrect information about services, there are several checks and balances (from internal systems to EOBs to beneficiaries) in place to minimize fraud.

• The system is designed to prevent “double-billing” for an individual. For example, whenever a Behavior Analyst is present during a session with the RBT, we are only allowed to request reimbursement for the Behavior Analyst's services. If we were to request reimbursement for both, the TRICARE system would immediately flag that and deny the payment. The exception to this “rule” occurs when the Behavior Analyst is meeting with you at the same time as the RBT is engaged in therapy with your child. In that case, there are two separate beneficiaries (you and your child, receiving different services at the same time). The bottom line is that the TRICARE system is very strict about this (which is why we also can’t be present at therapy delivered by another provider, such as speech!).

• TRICARE carefully reviews and requires strict adherence to the rules and regulations outlined in the TRICARE Operations Manual (affectionately known as “The TOM”). I know that many of you have had us send you a revision of your child’s progress report/treatment plan based on a TRICARE review.  This is despite the fact that we are highly experienced and aware of those TOM rules, which is further proof that the TRICARE system is not about to let anything slip through the system which shouldn’t be allowed.

• And finally, audits. TRICARE conducts, at a minimum, a yearly audit of services. If all the i’s are not dotted and all the t’s are not crossed, TRICARE will “recoup” money that has been paid to the provider, require a follow-up audit, and, if that audit is not passed with flying colors, will require the provider to submit verification documentation with every request for reimbursement of a service.

 

I know that was a lot of information, but I felt it was important for you to feel secure about how the TRICARE system functions to prevent the kind of actions reported through the Medicaid system. Those reports make me angry and sad and, well, embarrassed for our industry.  There is no denying that providing ABA services is, ultimately, a business. But at Green Box, we believe strongly that the primary function should not be to make as much money as possible, but to do as much good for the individuals we serve as we are able.