Using OBM to Maintain Compliance to Clinical Documentation & Prevent Thousands of Dollars in Lost Revenue

By Matt Linder, M.A., BCBA

Executive VP, DiNovi & Associates

False claims violating the Federal Claims Act, can result in civil penalties of up to $11,000. BCBAs tend to struggle with their billing practices, with the activity taking on aversive properties in several cases.  As caseloads increase and the odometer starts rolling, one can quickly fall behind in the timely submission of billing documents if you don’t find a way to stay on top of them.  Like many other ABA providers, our company has experienced delays in the timely submission of documentation (e.g., supervision notes) and we set out to try and improve the submission process with an Organizational Behavior Management (OBM) intervention.

In leading up to the project, we found ourselves in a situation where only 55% of supervision notes were submitted on time each week.  The first thing we tried, in an effort to rectify the situation, was email prompts.  They were a straightforward “Hey, we noticed that you haven’t submitted your documentation yet, please get them in as soon as possible.”  Most of the time, the BCBA would promptly respond with a “no problem, I will get them submitted very soon” and end up not following up. 

Late submissions were starting to take a toll on the company as a whole, with a significant number of cases being dropped by insurance companies due to a lack of adequate supervision documentation and not collecting payments after the consultant was already paid.  It goes without saying, that the company was starting to lose tens of thousands of dollars a year.  Additionally, the staff associated with dropped cases were adversely impacted – their jobs were in jeopardy if we couldn’t transfer them to a new case. This could, of course, led to higher rates of staff turnover when working with hundreds of learners. Lastly and most importantly, this had a potentially harmful effect on the learners.

We decided to look to OBM for a solution, and here is how we did it:

With the hard work and dedication of Maggie Rudd, M.A., BCBA, who was integral in carrying out the project, we implemented a lottery system that distributed monetary bonuses on a variable magnitude schedule ranging from $50-$500 per week.  To be eligible for the lottery system, a BCBA had to submit 90% of his/her supervision notes in a timely fashion into our online system every week. If the criteria were not met, the BCBA would have to physically come into the office to complete the notes under supervision, and several of our BCBAs lived in excess of 100 miles from our headquarters.  Before we began, all of our BCBAs had to demonstrate proficiency in our online billing system by passing a quiz to 100% accuracy.

We actually had two lotteries running simultaneously due to the fact that some BCBAs have many more clients than others, so our weighted lottery entered a BCBA into the system one time for each supervision note entered correctly.  Additionally, our unweighted lottery entered each BCBA into the system one time if they entered their documentation correctly, regardless of the number of cases.  Two lotteries did a few things for us.  First, the weighted lottery recognized the extra work that BCBAs with large caseloads put forth by making it more likely they would contact our incentives.  Secondly, the unweighted system leveled the playing field for the BCBAs with smaller caseloads; this way, everyone had the same chance of winning regardless of the number of notes entered.

Eventually, we started thinning the incentive schedule and introduced a self-monitoring component to submissions.  For thinning, we lengthened the time interval on which each payout was based from one-week to two-week intervals, and later to four weeks.  At four weeks, the incentives changed from the original $50-$500 range to $150-$1000 for timely submissions across all four weeks. Best practice suggests that the magnitude of the reinforcer should increase as the response requirements increase.

The logistics involved with having someone manually check all of the submissions to ensure participants met the note submission criteria occasioned the addition of a self-monitoring component.  To relieve this burden on the company, self-monitoring was arranged such that the BCBAs would enter their information into a locked spreadsheet, shared with the other BCBAs, so they could publicly see who was submitting notes on time.

And the results?  We haven’t lost a single case due to untimely documentation since beginning the lottery system. In fact, we’ve nearly doubled our revenue year to date from this funding source. Additionally, we have anecdotal evidence of social validity from talking to BCBAs who try to go the extra mile to submit their documents on time in order to be eligible for the lottery.  We are in the process of writing up the study for a peer-reviewed journal, so if you are interested in learning more about the specific procedures and results, keep an eye out.  In the meantime, if you have any questions about what we did, please email me at [email protected]

As the Executive Vice President at DiNovi & Associates, Matt provides both operational & clinical leadership to the entire organization which includes NJ, Eastern PA, Northern Delaware, NY, and worldwide via remote video consultation. Matt executes the principles of organizational behavior management (OBM) on a daily basis both within the organization and across schools. He draws experience from behavior analytic work with adults and children in residential, school and vocational settings. With experience providing clinical services to individuals with behavioral needs added to the years of experience living with a sister on the autism spectrum, Matt is able to analyze and approach various behavioral scenarios with a unique insight. As a Certified Safe and Positive Approaches trainer, he exhibits particular expertise in managing individuals in crisis situations, creating therapeutic behavior change, training parents and staff members on behavior plans, function-based interventions, and matching appropriate behavior principles to individual situations. Within a comprehensive knowledge of behavioral analytic principles, Matt expresses more specific interest in secondary principles of behavior change procedures, alternative methods of functional behavior assessment, matching law, and transfer of stimulus control.