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Behavioral Analysis Medicaid Providers: Florida’s Latest Enforcement Target

behavioral analysis medicaidBy: Matt Fischer

Florida’s Agency for Health Care Administration (“AHCA”) is the state’s chief health policy and planning organization.  AHCA is also responsible for the state’s Medicaid program.  One of the agency’s latest targets are behavioral analysis providers who treat children with autism.  Recently, AHCA imposed a temporary six-month moratorium on enrollment of new providers due to newly discovered fraud and abuse.  AHCA states that the temporary moratorium will allow the agency the time to complete a full assessment of the current provider population.  In other words, all behavioral analysis providers will experience heightened scrutiny in the coming months if not already.  This can include in-person interviews and requests for records.  Given this increased regulatory action, it is important for behavioral analysis business owners to be aware of the audit process and to prepare for likely future reviews.

Here are a few of the notable findings cited by AHCA regarding the identified fraud and abuse:

▪ Providers attempted to bill “unbelievable hours” (i.e. more than 24 hours per day, more than 40 hours per week, and billing in excess of 31 days in a row).  One provider tried to bill for more than 250 days in a row.

▪ Providers falsified their qualifications, exposing patients to behavioral analysis services from unqualified providers.

▪ Miami-Dade currently has an “abnormally high” ratio of providers to recipients – 8,175 behavioral analysis providers enrolled in the Medicaid program compared to 5,676 recipients receiving those services.

▪ Some of the Medicaid recipients were also enrolled as behavioral analysis providers.

AHCA’s press release and moratorium documents can be found here:

Under Florida law, an overpayment includes any amount that is not authorized to be paid such as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.  If overpayments are found following an audit, a provider will receive a preliminary audit report which will list the calculated overpayment amount and the reasons for the determination.  A provider will then have several options with a later option to challenge the action before an administrative law judge. With audit scrutiny on the rise, healthcare businesses need to ask: are we ready?