Applied Behavior Analysis (ABA) is the standard of care for those affected by an Autism Spectrum Disorder (ASD). Payers must be able to detect and deter those uncommon providers and beneficiaries who attempt to abuse or defraud claims systems. While cases may be few in number, the losses are substantial and they affect both the bottom line and ultimately the quality of care.
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- Identify abusers of the healthcare system, both providers and beneficiaries
- Introduce program reform measures and monitor results
- Reduce healthcare costs over time
- Recover funds
Billing fraud and abuse affecting Applied Behavior Analysis (ABA) & Autism Spectrum Disorder (ASD)
Fraud is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment.
What is Fraud?
- Submitting claims for services not provided or used
- Falsifying claims or medical records
- Misrepresenting dates, frequency, duration or description of services rendered
- Billing for services at a higher level than provided or necessary
- Failing to disclose coverage under other health insurance
- Refers themselves or a partner provider to perform a service, usually for a financial incentive
Abuse means actions that are improper, inappropriate and outside acceptable standards of professional conduct or medically unnecessary.
What is Abuse?
- Pattern of waiving cost-shares or deductibles
- Failure to maintain adequate medical or financial records
- Pattern of claims for services not medically necessary
- Refusal to furnish or allow access to medical records
- Improper billing practices