In a recent report published by the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), it was concluded that the Medicaid program in the state of Maine made improper fee-for-service payments of at least $45.6 million for rehabilitative and community support (RCS) services furnished to children diagnosed with autism spectrum disorder (ASD) that were found to out of compliance with Federal and State requirements. In the wake of these findings, HHS-OIG is recommending that the State should refund $28,796,366 to the Federal Government to rectify the improper payments, exercise further review on services that were identified as potentially improper payments, work with providers to address knowledge gaps in RCS services documentation standards, and conduct periodic reviews of the Medicaid payments made for RCS services going forward.

What Are Rehabilitative and Community Support Services?

RCS services are designed to aid children who have been diagnosed with developmental disabilities to work on skills that will aid them in being able to perform skills more confidently in areas of daily living, as well as supporting functioning both at and away from home by assisting with behavioral management. One of the most common therapeutic approaches used to support children and adults with developmental disabilities, like ASD, is Applied Behavioral Analysis (ABA). ABA services include therapeutic techniques, such as:

  • Mand Training
  • Discrete Trial Training
  • Natural Environment Training
  • Modeling

HHS-OIG Audit Sample Results

Of the 100 total enrollee-months that were sampled as part of this audit, it was found that 92 of the samples showed improper payments. The errors were identified as follows:

  • Comprehensive assessment missing or did not include staff/parent signatures (81)
  • Session notes did not meet documentation requirements (64)
  • Treatment plan did not include a parent signature, or the plan was missing (30)
  • No provider credentials (20)

Additionally, 95 of the samples showed potential improper payments. The errors were identified as follows:

  • Session notes did not contain complete descriptions (94)
  • Non-therapy time (92)
  • Unallowable recreational or academic activities (34)

The Importance of Appropriate Documentation

The errors identified in this audit underscore the importance of utilizing proper documentation techniques during the provision of healthcare services. A vast majority of healthcare services have documentation requirements that are regulated at the State and/or Federal level, and these must be met in order for appropriate reimbursement to be made for the rendering of these services.

How Can LW Consulting, Inc. Help?

At LW Consulting, Inc. (LWCI), we are committed to offering a comprehensive range of services to assist our clients with compliance and risk management in behavioral health settings. Our certified team of compliance experts are able to provide specialized expertise to behavioral health providers across the full continuum of care delivery. Some of our current behavioral health services include:

  • ABA Audits and Compliance
  • Behavioral Telehealth Auditing
  • Billing and Coding Audits
  • Education and Training
  • Emerging Treatment Management
  • Expert Witness and Appeals
  • HIPAA Compliance
  • Medical Necessity Reviews

LW Consulting, Inc. (LWCI) offers a comprehensive range of services to assist your organization in maintaining compliance, identifying trends, providing education and training,  or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!