Applied behavior analysis (ABA) providers must comply with medical documentation and billing practices listed in the TRICARE Operations Manual (TOM), Chapter 18, Section 4; state and federal regulations; and provider participation agreements, policies and guidelines at all times. Providers who fail to demonstrate compliance are subject to additional training, payment recoupment, penalties, and/or more severe administrative actions as required by law and contract.
HNFS reviews provider billing practices to verify services ABA providers bill TRICARE for are:
- TRICARE-approved services under the Autism Care Demonstration (ACD).
- Supported by clear and complete progress notes (medical documentation).
Please familiarize yourself with the types of reviews and guidelines.
Keys to success
- Becoming familiar with TOM, Chapter 18, Section 4 requirements to ensure medical documentation and billing practices are in compliance.
- Documenting all required elements in progress notes.
- Ensuring claims billed are supported by corresponding medical documentation.
- Providing services in line with adaptive behavior services (ABS) approved CPT code definitions and requirements.
- Avoiding exclusions.
Autism Corporate Services Provider (ACSP) groups and sole ABA providers are subject to a minimum of 30 record reviews annually. These include administrative and medical documentation reviews, and a review of one medical team conference progress note (if available).
Separately and on an ongoing basis, HNFS reviews CPT® code billing practices of West Region ABA providers to ensure compliance with TOM requirements.
REVIEWS FOR NEW PROVIDERS
- As of July 1, 2021, HNFS monitors all new network and non-network ACSPs/sole ABA providers during their initial 180 days of TRICARE West Region participation.
- The 30 annual audits frequency does not apply to new providers.
- Following the 180 days, we will review a minimum of 10 records for clinical documentation and claims submission for consistency with program.
- We will share audit results with new providers, and if necessary, provide education to address inconsistencies with program requirements.
CPT Code Reviews
HNFS reviews billing practices of HNFS West Region providers to ensure compliance with ACD and ABS CPT code requirements. This includes verifying ABA supervisors render a minimum of one direct visit per month for CPT 97155.
IMPORTANT: A 10% penalty will be applied to all claims for the authorization period in which the CPT 97155 requirement is not met. Exception: The 10% penalty may be waived if no CPT 97153 services were rendered that month.
Claims billed that do not meet ACD requirements are subject to denial or recoupment.
Please visit our Billing page for more information on CPT code requirements.
HNFS monitors ABA claims data to identify and prevent potentially fraudulent billing practices. Anti-fraud software is used to review claims data and detect potential issues that may include:
- High-dollar, erratic, or inconsistent billing and coding patterns.
- Changes in billing frequency.
- Concurrent billing (i.e., billing for two services at the same time).
- Misrepresentation of provider (i.e., filing for a non-rendering provider or non-authorized provider).
- Claims patterns of “impossible days” (provider’s total claims exceed 12 hours per any given calendar day).
- Patterns of high claim error rates.
If suspect billing patterns are identified, HNFS engages providers to address the findings and provides education on TRICARE requirements to mitigate ongoing issues. Following the education (within 180 calendar days), HNFS conducts post-payment reviews to verify any suspect billing patterns are resolved. Providers with ongoing suspect billing patterns are referred to our Program Integrity department.
Medical Documentation Reviews
HNFS conducts medical record documentation reviews to ensure compliance with the requirements listed in TOM, Chapter 18, Section 4. These reviews evaluate whether:
- Claims are supported by corresponding medical documentation.
- Progress notes contain all required documentation elements.
- Services documented in progress notes are in compliance with ABS TRICARE-approved CPT codes.
- Any exclusions were rendered during the session.
Please visit our Progress Notes and Exclusions pages for additional details.
MEDICAL DOCUMENTATION REVIEW PROCESS
As of Aug. 1, 2021, ACSPs/sole ABA providers must submit medical records to HNFS in response to review requests. Please ensure you respond to review requests on or before the due date specified.
- HNFS contacts (either by phone or email) ACSPs/sole ABA providers to alert them to an upcoming audit.
- HNFS sends a written request for medical records the provider/group.
- Providers must respond to the written request promptly. Records not received by the due date will negatively impact the audit score.
- Upon receipt, HNFS conducts the review to ensure medical records are compliant with ACD requirements.
- After completing the review, HNFS sends a written summary to the provider detailing specific findings.
- If applicable, HNFS assigns online training, targeting error types identified in the audit. Note: ACSP provider groups may determine which individual providers from their group are to complete assigned online training.
- HNFS performs a follow-up with a final group of reviews. Additional action may include but is not limited to probe audit, prepayment review and/or referral to the Program Integrity department.
Important notes regarding the review process and scoring
- Medical documentation received after the due date is a negative score.
- A determination that indicates recoupment is necessary is a negative score.
- A final score of 75% or greater for all records is a passing score.
- Providers who do not achieve a passing score are referred to the Program Integrity Department.
Audit findings and/or the provider’s final score in the audit may result in any or all of the following:
- Outreach and education
- Payment recoupment
- Referral to HNFS Program Integrity
- Probe audit
- Placement onto prepayment review
- Progressively more severe administrative actions, commensurate with the seriousness of the identified problems, and consistent with Chapter 13 and 32 CFR 199.9