What to do when the auditors come to your ABA agency.

Todd A. Ward, PhD, BCBA-D 

President, bSci21Media, LLC

Jamie Pagliaro

General Manager, Rethink Behavioral Health

Sarah Schmitz, CPC, CPB

President and Owner of Comprehensive Billing Consultants, LLC

In last month’s article, titled “Human Resources for the ABA Entrepreneur”, we touched on Skinner’s grand vision for the field.  His writings covered virtually every topic pertaining to behavior, especially “big picture” topics related to societal-level behavior problems.  To Skinner, behavior analysis wasn’t a science of autism, it was a science of behavior in all of its complexity.

In his landmark book Science and Human Behavior, Skinner (1953) devoted several chapters to untangling said complexity in his discussion of controlling agencies, wherein a relatively well organized group provides reinforcers or punishers in a manner likened to “ethical control” (Skinner, 1953, p. 333).  One broad class of controlling agencies he discussed related to those of government and law.  Skinner noted that governmental agencies transform the “good” and the “bad” of ethical control into “legal” and “illegal” behavior.  Moreover, it was Skinner’s view that governmental agencies particularly operate almost exclusively as administers of punishment for illegal behavior rather than reinforcement to strengthen legal behavior.  

Those of you at the helm of Applied Behavior Analysis (ABA) service provider companies might do well to take another look at what Skinner was saying, because controlling agencies are directly relevant to your chosen profession.

The specifics of how modern day controlling agencies impact your ABA provider were well articulated in a recent webinar presented by Sarah Schmitz, CPC, CPB of Comprehensive Billing Consultants, LLC, and sponsored by Rethink Behavioral Health.  The webinar, aimed towards owners of ABA providers, discussed the many types of audits one can experience, the broader regulatory context that accompanies audits, and strategies to ensure your audit experience runs smoothly. 

At its most basic level, an audit functions to ensure compliance with an agreement between two or more parties.  An audit can be thought of as a feedback mechanism to ensure agencies are following the rules pertaining to the products and/or services provided by the agency. The “rule givers” in this case relate to agencies with regulatory power over ABA service providers – Skinner’s (1953) controlling agencies – and the audit serves as the primary mechanism with which the agency provides punishers for practices that do not comply with policies.

So who are the controlling agencies pertinent to ABA service providers?  Schmitz discusses several, including:

• The U.S. Department of Health & Human Services

• The Centers for Medicare and Medicaid

• The Agency for Healthcare Research and Quality

• The Joint commission on Accreditation of Health Care Organizations

• The National Committee for Quality Assurance

But wait, it doesn’t stop there!  You can think of the above list as the “rule givers” – those who generate the polices to be enforced – but Schmitz further outlines agencies that enforce policy compliance, including:

• The Office of Inspector General

• Recovery Audit Contractors

• Zone Program Integrity Contractors

• Audit Medicaid Integrity Contractors

• Medicaid Fraud Control Units

• Claims Error Rate Testing Programs

• Anyone contracted through your funding source.

You may recall a previous article in which we discussed a milieu of socio-cultural factors that can affect the quality of your company’s services within the context of the metacontingency (see Do you have a quality ABA service provider?).  The two preceding lists constitute the major players in that milieu!  Such agencies have the power to bring stiff penalties ranging from fines to a complete shutdown of your provider if you are found to be out of compliance with policy.

So what is a provider to do in order to ensure compliance during an audit?  Schmitz provides some tips, a few of which are as follows:

1) Read contracts before signing them. This might sound like common sense, but the devil is in the details…and in the motivation to read through complex contracts filled with “legaleze” in the first place.

1) Research what is expected per company regulations. Don’t assume that every single regulatory detail will be outlined in your contract.  Oftentimes, contracts may refer the reader to other rules and regulations without detailing them in the agreement itself.  In particular, you should familiarize yourself with the Payment Policy & Medical Guidelines and the Medical Necessity Guidelines for each funding source.

2) Develop processes built around the audit process.  Specifically, you should develop company policies and procedures that directly reflect regulations and requirements.  You should also develop a compliance plan for your organization, which can serve as an internal mechanism to “self-audit” before a visit from an external regulator.  Lastly, plans, policies, and processes should be aligned with job descriptions and expectations that are spelled out in writing for your staff.

If you do receive an audit, Schmitz recommends to first determine the scope of the audit.  For example, the audit could cover your entire company or a particular insurance claim.  Secondly, if an auditor makes an in-person visit, set up a workstation for them to facilitate the process.  There isn’t any reason to make life more difficult for someone who has regulatory power over your company.

Has your company received an audit?  Tell us about it in the comments below and please share any tips that weren’t mentioned above!

About Rethink Behavioral Health

Rethink Behavioral Health provides the tools every behavioral health provider needs to manage their practice and deliver quality ABA treatment effectively & efficiently. Rethink’s easy to use web-based software streamlines client care with sophisticated yet intuitive tools for both clinicians & administrators. For more information, visit http://www.rethinkbh.com.

About Comprehensive Billing Consultants

With over 19 years of experience combined with our team in Medical Coding and Billing, Comprehensive Billing Consultants specializing in ABA therapy and autism related billing. Our qualifications include medical billing and coding specialist certifications, inpatient coding specialist certification, medical record management, business management, credentialing and contracting, and practice management consulting. For more information, visit http://comprehensivebillingconsultants.com.

Todd A. Ward, PhD, BCBA-D is President of bSci21 Media, LLC, which owns bSci21.org and BAQuarterly.com.  His company aims to disseminate behavior analyisis to the masses through non-academic publication outlets.  Todd is an editorial board member for Behavior and Social Issues and previously a Guest Associate Editor for the Journal of Organizational Behavior Management.  He has worked as a behavior analyst in day centers, residential providers, homes, and schools, and served as the director of Behavior Analysis Online at the University of North Texas.  Todd’s areas of expertise include writing, entrepreneurship, Acceptance & Commitment Therapy, Instructional Design, Organizational Behavior Management, and ABA therapy. Todd can be reached at [email protected]