Be Ready for Your ABA Insurance Audit: Key Tips

be ready for your aba insurance audit

Navigating ABA insurance audits requires meticulous preparation and ongoing vigilance in billing practices. This guide outlines essential strategies to ensure compliance, enhance billing accuracy, and streamline the audit process for ABA providers. It highlights the importance of understanding audit triggers, maintaining thorough documentation, and adopting proactive measures to support audit readiness.

5 Key Insights Discussed to Prepare for an ABA Insurance Audit:
  1. Audit Triggers and Importance: ABA insurance audits verify adherence to billing standards, prevent fraud, maintain quality care, and highlight correctable errors.
  2. Audit Readiness: Practices should ensure accurate documentation, understand billing codes, and maintain updated credentials to prepare for audits.
  3. Effective Audit Management: Organized communication, tracking of interactions, and understanding each insurer's audit process are essential for smooth audits.
  4. Continuous Improvement: Regular training and feedback integration from audits improve service delivery and billing accuracy.
  5. Professional Services: Outsourcing billing and engaging with professional audit support can enhance efficiency and compliance.

Understanding ABA Audits

Audit...kind of a scary word, right? No one likes to undergo an audit of any kind.

You may be thinking, "I don't have the time for this!" or "What if I fail the audit?". However, let's look at some of the reasons why insurance companies perform audits. Believe it or not, there are some positives for the world of ABA care!

Why ABA Audit's Are Important
  1. Ensures adherence to billing standards: ABA insurance audits are conducted as a vital part of the oversight process by insurance companies to ensure that billing practices adhere to agreed-upon standards and regulations. These audits are designed to verify the accuracy and integrity of the billing records submitted by ABA therapy providers.
  2. Prevent fraud and abuse: The primary reason for conducting audits is to prevent fraud and abuse, ensuring that the services billed were indeed provided and are clinically appropriate for the patient’s treatment plan. Audits also serve to verify that the coding and billing for services accurately reflect the care delivered, aligning with current coding standards and billing regulations.
  3. Maintaining quality care: Beyond compliance and fraud prevention, ABA insurance audits play a crucial role in maintaining the quality of care. They help insurance companies and providers alike to identify areas where practice management may be improved, including the efficiency of documentation processes and the effectiveness of the therapy being provided.
  4. Highlights errors that can be Avoided: Audits can highlight discrepancies or inconsistencies in billing practices that, if addressed, can streamline operations and enhance the overall service delivery. Thus, while they may seem daunting, audits are an essential mechanism for upholding the standards of care and ensuring that patients receive the appropriate level of support and intervention.

ABA insurance audits have become increasingly common, reflecting the growing demand for ABA services due to the rising number of patients with autism and related disorders.

These audits, which can be routine or triggered by specific concerns such as outlier payments, billing of new procedure codes, or complaints, are now considered a certainty rather than a possibility for most ABA providers.

The frequency and certainty of these audits underscore the importance of maintaining accurate and comprehensive documentation, understanding payor contracts and manuals, and implementing proactive audit preparedness measures. Key strategies include familiarizing oneself with each payor's expectations, conducting internal audits, and having a clear response plan for audit requests.

What to Expect When Your ABA Practice is Audited

An insurance company or federal/state agency may contact your clinic either via letter, email, or phone call. They will explain who they are, what patient(s) they are wanting records for, and what time period of care they need the records for.

If it is an insurance company, they will be auditing the records of claims that you filed to them for certain patients. They will most likely want this type of information:  Patient’s intake forms, session notes for all services performed for that patient during the allotted time frame, etc.

If it is a federal or state agency that is auditing an insurance company (e.g. The Office of Inspector General auditing a state Medicaid program), then the federal or state agency would probably want this type of information: Patient’s intake forms, session notes, copies of claims that you filed with the insurance company for that patient during the allotted time frame, and more.

The insurance company or federal/state agency will be reviewing over the information you submit to them, to see if the medical records and/or billing statements follow the guidelines set down by them for care, medical records, and billing.

Audits can last a few weeks to a few months, depending on the individual and/or the particular company performing the audit.

ABA Audit Pitfalls

Below are common problem areas clinics face in audits related to ABA record documentation and procedures:

  • Not listing the length of the session on the session note
  • The rendering provider’s name was not legible on session note.
  • The rendering provider’s provider type/level was not written on session note.
  • Lack of detail when listing the content of the session.
  • Listing lots of details being worked on that are not part of the approved treatment plan. Not listing details of what they are working on, that are part of the approved treatment plan.
  • Not gaining parent signature on a session note when applicable/needed.
  • Not having session notes for certain services performed
  • Not providing information on some session notes regarding clinical status, content of the session, summarizing the techniques attempted, describing the response, summarizing the patient’s degree of progress.

While we've encountered numerous issues causing clinics to struggle with audits, the following is a brief overview highlighting key problem areas.

stressed about aba insurance audit

Key Components of an Audit-Ready ABA Practice

To safeguard against ABA audit triggers and uphold high billing standards, practices must remain vigilant and proactive in several key areas. This includes staying current with billing regulations, implementing strong internal controls, conducting thorough security assessments, and ensuring the privacy of protected health information.

  • Maintaining up-to-date knowledge of the latest billing regulations and payer requirements is essential to avoid non-compliance that could trigger an audit.
  • The establishment of internal controls and the division of duties within ABA practices are necessary to monitor and correct billing inaccuracies, thus mitigating the risk of audit findings.
  • Regular security audits and risk assessments should be conducted to uncover potential vulnerabilities and ensure the effectiveness of existing security measures.
  • Implementing safeguards to prevent incidental disclosures of protected health information is crucial, including the adoption of reasonable precautions and the sharing of only the minimum necessary information.
Accurate and Consistent Documentation

Effective documentation in ABA practices is fundamental for ensuring thorough care and meeting insurance requirements. Here are key aspects that highlight its importance.

  • Accurate clinical documentation is critical for ABA practices to ensure clients receive appropriate care and to comply with payer requirements.
  • Insurance payers scrutinize therapy sessions, and weak documentation can lead to denials of coverage for client therapy.
  • Practices must establish robust documentation systems to record and store detailed patient information, therapy sessions, and progress, which supports both successful billing and client progress tracking.
Billing Consistency and Proper Use of Billing Codes

Accurate understanding and application of ABA billing codes are essential for compliance and effective therapy billing. Consider these crucial points.

  • Category I ABA billing codes must be accurately documented and understood by clinical staff to ensure proper billing for services.
  • Precise use of ABA billing codes is critical for ABA therapy billing.
  • Time-based billing codes in 15-minute increments are fundamental for ABA therapy to accurately reflect time spent with clients.
  • It is important to know what each insurance company requires regarding supervision and modifiers.
  • Regular staff training on modern standards and updates in ABA practice coding requirements is essential for consistency and compliance with billing practices.
Clear Communication and Tracking

Efficient communication and organization are key to navigating the audit process effectively. Here are strategies to manage interactions with auditors.

  • Assign one person as the main contact for the auditor.
  • Respond promptly to all inquires and requests for documentation.
  • Ask for expected response times from the auditor and then follow up if you have not heard from them by the appointed time.
  • Stay organized. Keep track of dates of meetings, phone calls, etc. Note what documents were sent and when.

"For every minute spent organizing, an hour is earned."

Benjamin Franklin

Updated Credentials and Certification Requirements

Maintaining updated credentials and early initiation of the credentialing process are essential for ABA practices to ensure compliance and facilitate smoother operations. Here are the key reasons why.

  • Maintaining updated credentials in ABA practices is crucial to prevent denied claims and the potential consequences of non-compliance.
  • The credentialing process for ABA therapists can take up to 90 to 120 days; thus, starting early is recommended, especially for new practices.
  • Being credentialed allows a medical practice to become an in-network provider, leading to consistent handling of billing codes, rates, and improved decision-making processes.
  • Credentialing also provides an ABA practice with better customer support, aiding in faster claim resolution and high-quality service through established relationships within insurance organizations.
  • Ongoing ABA credentialing and maintenance of certifications is also a requirement. You will need to follow each insurance companies processes for the re-credentialing process.

Consider ABA credentialing services to streamlining your credentialing and avoid issues.

HIPAA Compliance in ABA Practices

Although not an insurance audit, the specific focus of this article, another type of audit your clinic can be subject to would be by the Office for Civil Rights (OCR). These audits are part of the OCR's Health Information Privacy and Security Compliance program. The Office for Civil Rights (OCR) conducts audits of health clinics and other covered entities and business associates to ensure compliance with the HIPAA Privacy, Security, and Breach Notification Rules.

The HIPAA law falls under the jurisdiction of the U.S. Department of Health and Human Services (HHS), specifically managed by the OCR. The OCR is responsible for enforcing the HIPAA Privacy and Security Rules, ensuring compliance and investigating complaints related to the protection of health information

  • HIPAA, enacted in 1996, sets national standards for the use and disclosure of Protected Health Information (PHI) by healthcare providers, to which ABA practices must comply.
  • ABA service providers are obligated to follow HIPAA regulations including the Privacy Rule, the Security Rule for electronic PHI, and the Breach Notification Rule.
  • Outsourcing insurance billing can enhance the compliance with HIPAA by leveraging the expertise of third-party companies that specialize in navigating healthcare regulations.
  • Choosing a billing partner that is current with HIPAA compliance is crucial to integrating these standards throughout the practice's operations.
  • To maintain the integrity of PHI handling, verifying the billing company's adherence to HIPAA rules is fundamental in preventing legal repercussions and securing patient data.
Continuous Improvement and Training

Continuous training is vital for ABA therapy staff, enhancing the quality and effectiveness of client care. Here are the core benefits of a robust training program.

  • Continuous training for ABA therapy staff is crucial as it ensures the consistent and efficient delivery of interventions, leading to better outcomes for clients.
  • Ongoing training equips staff with the latest knowledge to maintain high standards of care and adapt to new methodologies, ensuring the effectiveness of services.
  • Create a culture of continuous learning by integrating feedback from audit findings into training programs for immediate improvement.
  • Embracing assigned training programs and personalized learning can empower ABA staff, leading to a more knowledgeable workforce and improved client care quality.

Engaging Professional Services for Audit Support

Outsourced billing for ABA providers enhances financial efficiency and allows clinics to focus more on patient care. Choose a billing partner based on their expertise and your practice's specific needs.

  • Outsourcing ABA billing helps to optimize revenue cycle management, which is crucial for maintaining financial health without allocating additional in-house resources.
  • Third-party billing services increase practice productivity by managing multiple bills simultaneously and ensuring quick collection and resubmission of claims while also facilitating automatic verification of patients' insurance eligibility.
  • ABA billing services can lead to cost savings by eliminating the need for expenses related to salaries, training, and office supplies for in-house billing staff.
  • Partnering with a professional billing agency allows healthcare staff to devote more time to patient care and less to administrative tasks, thereby enhancing the quality of care, while also maintaining a steady cash flow and exploring additional revenue opportunities through trans-promotional marketing.

Choosing the right ABA billing company is crucial for the smooth operation and financial health of an ABA clinic! When evaluating potential partners, consider the following factors:

  • Years in Business: Demonstrates experience and stability in the field of ABA billing.
  • Accreditation with the Better Business Bureau (BBB): Reflects a commitment to integrity and customer satisfaction.
  • Certification for HIPAA Compliance: Ensures the company adheres to stringent privacy and security standards protecting patient information.
  • Expertise in ABA Specific Billing: Knowledge of ABA-specific codes, authorization processes, and insurance policies.
  • Proven Track Record: Positive testimonials, Google reviews and case studies from other ABA clinics.
  • Personal Service: Don't want to feel like a number? Sometimes going with a smaller business can provide you with more personal and customized service. Going with a large corporation can make you feel like "one of the herd" and you are lost in the crowd.

FAQ - ABA Insurance Audit

Q:  What is an audit in ABA?

A:  Most of the time, an "audit" means that an insurance company or federal agency is requesting documentation regarding a patient's treatment at your clinic that was billed to an insurance company. The insurance company or federal agency will be reviewing over documentation and claims submitted.

Q:  What triggers an insurance audit?

A:  Insurance audits can be triggered by various factors, including random selection to verify ongoing medical necessity, routine reviews by the insurance company for in-network providers, or as part of a larger audit involving state agencies by federal entities. The reasons for audits are diverse, ranging from ensuring compliance to assessing the accuracy of billing practices.

Q:  How often do ABA companies get audited?

A:  The frequency of audits for ABA companies varies. After failing an audit, a clinic might face a follow-up audit within 6-9 months. Failing again could lead to another audit within 3 months or even closer monitoring on a per-claim basis. Ultimately, the schedule depends on the insurance company's policies.

Q:  How will I know if my clinic passed the audit or not?

A:  Notification of audit results varies by insurance company. While sometimes not hearing back can mean your clinic passed, other times you may be informed through a Zoom meeting, a letter detailing the audit outcomes, or via the claim processing outcome if the audit was claim-specific. The method of communication is determined by each insurer's practices.

Q: Will my clinic have to pay back money to the insurance company after a failed audit?

A:  Whether your clinic needs to repay funds to the insurance company after an audit depends on the insurer's policies and audit findings. In some cases, an insurer might halt future payments for care rather than seek repayment. Other times, if a clinic passes part of an audit but fails another, the insurer may require repayment for the specific portion of claims that failed. The requirements can vary significantly between insurance companies.

NOTICE

At Advocate Insurance Billing, we strive to ensure the accuracy and reliability of the information provided in our articles. However, the content is for educational purposes only and should not be considered as a substitute for professional advice. We encourage our readers to conduct their own research as practices and regulations in the field of ABA insurance billing and ABA credentialing can change frequently. While we make every effort to keep our information up-to-date, we cannot guarantee that all content is free of errors or omissions.

NOTICE

At Advocate Insurance Billing, we strive to ensure the accuracy and reliability of the information provided in our articles. However, the content is for educational purposes only and should not be considered as a substitute for professional advice. We encourage our readers to conduct their own research as practices and regulations in the field of ABA insurance billing and ABA credentialing can change frequently. While we make every effort to keep our information up-to-date, we cannot guarantee that all content is free of errors or omissions.