Objective
Our objective was to determine whether the DoD appropriately paid for autism services in the TRICARE South Region. We focused on one-on-one applied behavior analysis (ABA) interventions1 (hereafter referred to as ABA services) across five nonstatistically selected ABA companies within the same geographic area in the TRICARE South Region that generally billed at the highest possible rate. Payments to the five companies were valued at $3.1 million of the total $71.2 million paid to all ABA companies for ABA services provided in the TRICARE South Region during CY 2015.
Background
TRICARE is the DoD’s managed health care program for active duty service members, retirees, and their family members. The Defense Health Agency (DHA) manages the TRICARE program. For eligible beneficiaries diagnosed with autism spectrum disorder, TRICARE provides reimbursement for ABA and related services.
Finding
The DHA made improper payments for ABA services to five ABA companies in the TRICARE South Region. Specifically, the ABA companies billed, and the DHA improperly paid for, ABA services under the following conditions:
- lack of documentation to support ABA services;
- misrepresentation of the provider who performed the ABA services;
- billing for ABA services provided while the beneficiary was napping;
- billing for two services at the same time;
- unreliable supporting documentation;
- billing for services while the beneficiary was not present; and
- billing for services performed by providers who were not authorized by TRICARE.
DHA personnel made improper payments because when DHA and contractor personnel selected ABA companies for review, they did not consider that certain indicators may help to identify improper payments, such as a high percentage of claims billed at the ABA supervisor rate, the highest rate. As a result, we project that the DHA improperly paid $1.9 million of the total $3.1 million paid to the five companies for ABA services performed in CY 2015.
Recommendations
We recommend that the Director, DHA:
- conduct comprehensive medical reviews of ABA companies in the TRICARE South Region that have specific indicators of improper payments, and
- review claims from the five ABA companies in our sample and provide the results of the review to the DHA Program Integrity Office for appropriate action.
Management Comments Required
The Director, Defense Health Agency, did not respond to the recommendations in the report; therefore, we consider the recommendations unresolved. We request that the Director provide comments on the final report. To resolve and close these recommendations, DHA will need to demonstrate that it reviewed ABA companies that have specific indicators of improper payments, including the five ABA companies in our sample, and took appropriate action, such as recouping any overpayments.
This report is a result of Project No. D2016-D000CJ-0134.000