Applied Behavioral Analysis (ABA) therapy is an increasingly popular field in the mental healthcare industry. ABA providers often have to work intensively with insurance carriers to ensure their patients are qualified for various treatment strategies. This level of interaction and scrutiny means that as an ABA therapist you’re likely to go through several audits in the course of your career. Even though auditing for ABA practices is no longer a probability but a certainty.
While it’s a natural part of the industry, even the word “Audit” can feel understandably intimidating. Especially if you have a small ABA practice without the administrative staff technology to handle big claim inquiries.
Understanding the audit process helps keep it from feeling overwhelming, while also minimizing the risk of consequence if there is an honest error or incongruity that draws a red flag with the auditing insurance carrier.
The following is an essential overview of the auditing process and the things you can do to help keep your ABA practice audit ready.
What Triggers an ABA Audit?
Right off the bat, receiving an audit notice from an insurance carrier isn’t an immediate sign that your ABA practice is in peril. Pretty much every ABA practice gets audited at some point, and a single ABA therapist might be audited multiple times in their career.
Insurance carriers and payers institutions rarely disclose their audit triggering criteria. From their perspective, the element of surprise is an essential part of the auditing process. This underscores the need to keep your ABA practice as audit-ready as possible.
Though some specific circumstances are more likely to increase the risk of your ABA practice being audited. This includes things like:
- Outlier payments
- Above-average utilization rate
- Using new billing codes for new procedures
- Complaints from employees
- Complaints from your patients
- The frequent use of specific codes that other providers aren’t using in your area
- Previous errors or problems
- A past fraud claim
It’s also worth bearing in mind that random selection is also a part of the insurance carrier auditing process. Some practices and providers are simply chosen at random. Once again, it’s wise to implement protocols that keep your ABA practice ready for an audit, through industry-best compliance practices.
How to Reduce Your Risk of an Audit
Reducing your risk of being audited by an insurance carrier in your network or a public health institution starts with making every effort to be compliant. This includes making sure your in-house clinical and administrative staff receive annual OSHA and HIPAA training. This ensures that they meet all the BACB board and state provisions for delivering ABA therapy. It also provides you with a layer of insulation against liability if they commit an error.
Make sure to include specific training for any direct services, therapy sessions, and supervision sessions, as well as parent training, patient assessments, and all other relevant information collecting.
Things You Can Do to Prevent an Audit
Being audit ready proactively reduces your risk of being audited by a payer organization.
This includes covering some of the following things that increase your audit risk.
Prevent Inadequate Documentation
Insurance carriers and payers institutions always need to verify medical necessity and treatment guidelines. This calls for a thoroughly accurate and consistent level of documentation. Making sure you have adequate assessments, diagnostics, and treatment documentation from the onboarding process and beyond will flow through all other levels of documentation for all your patients.
This means each case will include:
- Detailed notes of services were provided
- How services were delivered
- The level of services was billed
- Concrete proof that the services provided were necessary
Establish Policies to Eliminate Billing Irregularities
Insurance carriers adore consistency in billing practices. To the point that fluctuating billing practices and irregularities in reimbursement rates are bound to trigger red flags in their auditing system.
Avoid Outliers from Geographic Peers
Insurance carriers and public health institutions used an array of analytics. This includes comparing your practice and individual providers with similar providers in your geographical area. If you are offering one or two specific services repeatedly that your shoulder-to-shoulder peers are not, they will note the deviation leaving you prone to excess scrutiny.
Maintain Updated Credentials
When state regulator agencies and insurance carriers change their credentialing certification requirements, you and every required provider or technician in your practice need to adapt accordingly. Then you need to proactively update your credentials with payers, state agencies, and any applicable public health institutions. If you continued to practice with outdated credentials that aren’t adequately updated on time, you are at risk of your license being revoked, denied payments, rejected claims, and intense audits.
Make Sure to Always Use Accurate Billing Codes
While it’s true that everybody makes mistakes, some errors look suspicious to insurance carriers and payer institutions. This includes things like accidentally using multiple CPT codes for different parts of therapy treatment. As something like this often looks to them like you are simply trying to increase payments/reimbursements without full justification.
Avoid HIPAA Violations
As we mentioned earlier, providing your staff with annual or perhaps bi-annual training helps reduce HIPAA violations, and insulates you against direct liability if there is a violation. Though even an accidental HIPAA violation can prompt a major audit. If possible, try to conduct HIPAA spot checks to make sure that everyone in your practice is maintaining airtight best practices with patient privacy information.
Proactively Work to Prevent Claim Errors
Every claim submitted to an insurance carrier needs to include all the correct client and billing information. While avoiding these simple claim errors can be time-intensive, it will go a long way toward reducing your audit risk, while also giving you the peace of mind that your practice remains audit-ready.
Hire a Third Party Medical Billing Service
One of the best ways to reduce your risk of being audited by a payer or public health institution is to outsource your medical billing needs to a third-party agency like Operant Billing Solutions. Not only does it free up your time to treat more patients, but you also get the peace of mind that comes from knowing highly trained medical billing experts are reviewing all your claims with the utmost scrutiny.
Any errors or missing information is then caught before the claim is ever submitted to the insurance carrier. Best of all, you get to enjoy a more consistent revenue stream to boot.