Ethics of Medicaid Fraud Q&A Scenarios and Questions with Dr. Jon Bailey

2 Ethics of Medicaid Fraud Q&A Scenarios and Questions with Dr. Jon Bailey
Expert Name: Karen Chung
Expert Title: CEO & Founder
Company Name: Special Learning, Inc.
Company URL: www.special-learning.com
Short Bio: Karen is the CEO and Founder of Special Learning. She graduated from Kellog and was introduced to the ABA field and ancillary therapies over a decade ago.

It became her life’s passion to share knowledge of these evidence-based therapies to the global community who either work or have a child/adult with Autism Spectrum Disorder (ASD) or a related disorder. She has become one of the thought-leaders in this space and is achieving her goal through the works of Special Learning, Inc.

Ethics of Medicaid Fraud Q&A Scenarios and Questions with Dr. Jon Bailey

During our Ethics of Medicaid Fraud Q&A live webinar with Dr. Jon Bailey, Dr. Bailey, along with our panelist, Michele Silcox, CEO and Founder and CEO ABA Therapy Billing and Insurance Services, provided thought provoking and practical responses to questions which were posed to them during this 10/3/2018 Live webinar. 

For each question below, and ones asked by the audience, Dr. Bailey and Michele did a wonderful job of approaching each problem with a dual lens – Ethics and Billing – to provide attendees with not only direct responses to questions posed, but also information on how to prevent issues from occuring by using proactive, preventive strategies. 

Ethical Billing Practice

  • “Is it an ethical practice for healthcare and other benefits to be contingent on a number of billable hours/month (i.e. full-time status)?“ I’m referring to employee benefits. Companies whose healthcare and benefits (401k, IRA, etc.) which are contingent on a BCBA billing a certain number of hours a month – regardless of what clients are being billed to or not. 
  • Is it ethical for employee benefits to be dependent upon full-time status (meeting the required hours/month)? Wouldn’t such a practice make individuals more likely to commit Medicaid Fraud under certain “low-hour circumstances” for the month, like holidays or cancellations, etc.?
  • “On the subject of contributions to provider fraud and in relation to “retailer service” private companies, how should a behavior analyst operate when that model within the organization (that) they are a part of itself may be somewhat responsible for susceptibility of Medicaid fraud, across even the entirety of the company? For example, companies that place pressure, or rather “highly encourage,” their employees to fulfill a certain number or hours or provide services to nearly any person with developmental needs?”

  • “Are organizations which primarily focus(es) on behavior reduction any more or less likely to commit Medicaid fraud?”

Safeguarding Against Fraud

  • “I am a small organization, in my 4th year of operation, I am in the middle of the Medicaid Audit. None of our errors have been intentional or fraudulent. In our file reviews, mistakes with billing have happened with human error. What do we do for the few issues of something that may have been double billed? In addition, some sessions are missed and never billed. The rep I spoke to said don’t change anything. I think catching our errors is better practice and shows better competency. What is the ethical answer?”
  • “… as a BCBA whose hours are billed by a separate billing company, do I or should I have the right to view the hours billed for my services to ensure fraud in not occurring under my name without my knowledge?”
  • “How would we know if our credential is being used fraudulently? I never thought of that happening, but I guess if my BCBA number is out there, someone could potentially use it!”
  • “How would you address situations where services are being billed and an RBT is present but actual behavior analytic services aren’t occurring? Many cases I’ve taken over had previously been receiving little to no oversight, training, or parental training. I’ve received extreme pushback when I take over and set a much higher expectation. Do we shape these behaviors over time, even if it feels like the sessions should require much more?”

How Does the BACB Code Work in Real Life? 

  • “I have a BCBA-D in my city who was falsified billing to Tricare for over $1 million, ordered to pay back about $800,000 of it but still has the credential of BCBA-D and is still seeing kids. Why wasn’t the BCBA D credential taken away?”
  • “… when an agency contracts with a funding source, that individual is required to operate under the BACB ethics in addition to the regulations or contract requirements set forth by the funding source. The funding source may have more specific requirements, for example regarding maintaining records, than the BACB may have outlined. I think it is extremely important for an agency to fully understand what the regulations are in the state they are practicing in; more often than not an agency enrolls/contracts with a funding source without understanding what the expectations are which can cause a myriad of problems. Can the panel speak to how the BACB ethics code interplays with external requirements of the funding source?”

How Do You Deal with Consequences? 

  • “How do you think the publicized “whistleblower” of ABA companies and fraud will affect future behavior of RBT’s who are essentially at the mercy of employers/supervisors (especially those who are gaining field work hours).”
  • “What are some steps to take if an employee wants to rectify fraudulent billing (whether it be intentional or unintentional) from an employer without risk of retaliation?”
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Being an RBT for me was extremely fun because where were you going to find a place where you can be completely silly without having to worry what people thought about you? This was the only job that made me feel like I could make a dramatic difference while being myself.

I also liked to be surrounded by people that had the same goals of wanting to help kids and the teamwork made the job much easier and more enjoyable.

Change and progress was the ultimate goal for our kiddos. The early intervention program was seriously only a miracle because I saw changes in the kiddos that from day one, you wouldn’t even recognize who they were.

Changes from being able to utter 3-4 words where they can only make a syllable from when they started, the behavior decreases in which kiddo that used to engage in 30-40 0 self-harm to only half, learning how to wait during games, table work where they use to swipe and drop to the floor if they had to.

My favorite was when the parents would tell us what amazing progress they were making at home. I used to tear up and felt for these parents so much because it was already difficult for them and now, they can trust and rely on ABA and the therapists knowing their goal was ours.

By Emma Rogers, BA, RBT

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