Individuals who are striving to do good and be good by others and set their standards high will do everything they can in their power to NOT engage in billing code fraud, waste, and/or abuse (misuse). Ethical concerns and situations do occur, but what makes it unethical is when they are discovered, and nothing is done to resolve the issue.
For further information pertaining to ABA Billing and Revenue Cycle Management see the following PowerPoint Presentation.
https://www.nc-aba.com/wp-content/uploads/2019/02/Silcox.pdf
I am going to present the following scenario using fictitious names as an example for others about what may happen and what may go unnoticed and unreported.
Two or three clients are receiving ABA services at a center. Client Jimmy is scheduled for session from 12:00pm – 3:00pm with his direct therapist Kate using code 97153. Client Joe is scheduled from 3:00pm – 6:00pm with his direct therapist Mark using code 97153. On the morning of, client Jimmy’s mom requests that session be extended an additional 45 minutes. Scheduler for the company reaches out to direct therapist Kate and asks her if she can extend her session. At first she agrees, but then within an hour remembers that she has something personal to take care of and cannot stay after 3:00pm.
At that point the Scheduler or Owner of the company should have reached out to Jimmy’s parent and explained that they would not meet the staffing requirements and that Jimmy would need to be picked up at 3:00pm.
However, that is not what occurred, instead Behavior Therapist Mark was scheduled and told he would be working with both Jimmy and Joe from 3:00 – 4:00pm. Joe’s supervising BCBA arrived at the center around 2:30pm. The BCBA was there to work with Joe and his therapist Mark, who let the BCBA know that he would be working with two clients at the same time from 3:00 – 4:00pm.
BIG RED FLAGS!!!!
The BCBA then located Jimmy’s supervising BCBA and had a conversation with her about the situation. Neither client was provided with social group codes on their previous insurance authorizations. Jimmy’s supervising BCBA was not able to stay and work directly with her client Jimmy.
Both BCBAs discussed the ethical dilemma that was about to occur. The Behavior Therapist Mark said he did not feel comfortable and was not sure how he would be able to work with two clients who are both young and extremely active at the same time. During this time, another Behavior Therapist chimes in and states, “This goes on all the time at the other center, and it has happened here too before”.
ALARMS ARE NOW GOING OFF!!!!
Joe’s supervising BCBA then contacts the Owner of the company via text message (needs this in writing) and expresses her concerns and lets the Owner know that she took over working directly with Joe and had the Behavior Therapist Mark go work directly with Jimmy.
Owner stated she would not bill either client for that hour. BCBA expressed that even if neither client was charged that what was occurring was wrong and that parents are expecting a particular type of service to be rendered to their child and not receiving it.
Concerns were addressed with www.ABAEthicsHotline.com and followed up with various insurance companies.
These situations and many other similar ones are happening and may continue to happen if others turn a blind eye, do not become familiar with Ethics and Billing, and are unsure of who to turn to in that moment.
Clients should always be reviewing billing statements to catch any situations like this where a client was scheduled and not billed or a billing code is being used incorrectly.
I advise anyone who is working in this field as well as parents/guardians to join ABA Groups either in-person or on-line. If something doesn’t seem right you should question it and if you don’t believe you are getting a professional and appropriate response, then you should contact the Ethics committee (see link above), contact the Behavior Analyst Certification Board www.BACB.com, and/or your insurance provider to report a grievance.