We determined whether the DoD appropriately paid for one-on-one applied behavior analysis interventions (ABA services) for the treatment of Autism Spectrum Disorder in the TRICARE North Region. The audit was requested by the Director, TRICARE Health Plan. The TRICARE North Region contractor paid 1,388,073 claim line items for ABA services, valued at $120.1 million, in 2015 and 2016.1
TRICARE is the DoD’s managed health care program for active duty service members, retirees, and eligible family members. The Defense Health Agency (DHA) manages the TRICARE program. For eligible beneficiaries diagnosed with Autism Spectrum Disorder, TRICARE provides reimbursement for covered ABA services. According to the Behavior Analyst Certification Board, “ABA is a well-developed scientific discipline among the helping professions that focuses on the analysis, design, implementation, and evaluation of social and other environmental modifications to produce meaningful changes in human behavior.” To receive payment, ABA companies submit claims to the TRICARE North Region managed care support contractor. Generally, health care companies (including ABA companies) are not required to submit patient medical records, such as ABA session notes, as
supporting documentation when submitting claims. However, DHA contractor personnel may request a medical record from an ABA company to verify that services were performed appropriately. Failure to adequately document medical care will result in complete or partial denial of the claim.
The DHA made improper payments for ABA services to companies in the TRICARE North Region. We statistically project that the DHA, through its contractor, improperly paid $81.2 million of the total $120.1 million paid to ABA companies in the TRICARE North Region for ABA services performed in 2015 and 2016. The DHA either lacked documentation or had insufficient documentation to support the payment to the ABA companies. The DHA did not detect these improper payments because the DHA did not perform comprehensive medical reviews on a statistically representative sample of ABA claims.
In a prior audit report (DoDIG-2017-064), we identified that the DHA made improper payments for ABA services to five ABA companies within the same geographic area in the TRICARE South Region that generally billed at the highest possible rate. As a result, we projected that the DHA improperly paid $1.9 million of the total $3.1 million paid to the five companies for ABA services performed in 2015. We recommended that the Director, DHA, conduct comprehensive medical reviews of ABA companies in the TRICARE South Region that show indicators of improper payments, including, but not limited to, companies billing 6 or more hours a day for children 4 years of age or younger, and compare medical records to ABA company claims to determine whether the charges were appropriate.
During our audit of the TRICARE North Region, we identified systemic improper payments that included not only high-risk ABA companies, but ABA companies with low risk profiles as well. Because we identified significant improper payments across the TRICARE North Region, it is probable that the TRICARE South and West Regions also have ABA companies that are not properly documenting covered ABA services provided to TRICARE beneficiaries.
We recommend that the Director, DHA:
Revise policy to require annual comprehensive medical reviews on a statistically representative sample of ABA providers’ claims for the TRICARE
North, South, and West Regions to ensure that an adequate number of claims are reviewed. Reviews should compare the beneficiaries’ session notes to the providers’ claims to determine whether all required documentation exists and adequately supports payments received.
The reviews should cover claims from 2015 and all future years.
- Review and pursue appropriate action, such as recouping any overpayments, on the claims in our sample for which there was insufficient or no documentation from the ABA companies.
Management Comments and Our Response:
The DHA Director agreed with our finding and recommendations. The Director agreed with and implemented the recommendation to revise policy to require annual comprehensive medical reviews on ABA claims for the TRICARE Regions from 2015 and all future years. Therefore, the recommendation is resolved and closed.
The Director also agreed to review and pursue appropriate action, such as recouping any overpayments, on the claims in our sample for which there was insufficient or no documentation from the ABA companies.
Therefore, the recommendation is resolved. We will consider the recommendation closed once we receive and analyze supporting documentation to ensure that it addresses our recommendation.
Health care claims data are made up of multiple claim line items. For Example, one claim may have four claim line items. Each line item represents a different date of service or a procedure that a provider performed.