Scenario: Should the BCBA be allowed to practice if we do not know what caused the drop from the insurance? Are there any additional supervision steps that should be taken with this provider?

Relevant background: We have a BCBA on staff who has been dropped by Medicaid in a state other than AZ which has led to an AZ insurance company also dropping her. What obligations do we have as a company to investigate, and what steps are recommended moving forward. All current clients are in network. The clients affected have been transferred. State license for dropped state is no longer active and BCBA reports they have not practiced in that state in years. Additional steps if any need to be taken to ensure we have done our due diligence?

Possible solutions: Aftertalking to the BCBA they reported they had no idea and did not know what was going on. We have reached out to state Medicaid that dropped. They will not disclose due to the company not practicing in the state. We have further reached out to AZ based insurance that dropped; they will also not disclose. BCBA does not have any pending investigations etc. that are public.

Credentialing: Person is a credentialed behavior analyst/LBA

Committee Input (e.g., considerations for pathways forward, potential barriers, potential solutions):

Based on provided information, it does not appear that the company has any additional obligations to investigate and is left with the determination of keeping the BCBA on staff.  It would be valuable and responsible for the agency to look through the Medicaid Fraud Registry through the Office of the Inspector General for all current employees.  This resource may be able to provide information on the matter. 

As far as the BCBA with the claim, there are many regulations that would point to continuing to investigate this matter.

Ethics code 2.06 describes ethical standards for billing accurately, though the rules and regulations for what is considered “ethical” in terms of who can bill what billing codes varies per insurance contract. It is the BCBA’s responsibility to ensure all billing conducted under their license is occurring according to the accepted standards for that specific insurance company and plan. Ethics code 1.01 explains that BCBAs have an obligation to remain truthful and honest with those involved in their practice, and should make all attempts to conform to professional standards (1.02). This should include standards provided by the insurance companies.

Arizona Revised Statutes 32-2091 12 outlines “unprofessional conduct” as gross negligence (12e), violating state or federal law (12k), actions in another jurisdiction resulting in censure or probation (12n), and abandoning or neglecting clients without a transition plan (12v).

It is recommended that the BCBA do the following:

• Obtain documentation from the insurance company as to why they were dropped as a provider. This information should then be shared freely with the employer. It is possible that this action of transparency would result in the company being unable to retain the BCBA as a provider altogether. For example, if the company only contracts with UHC, for instance, and this provider has been permanently banned as a provider with UHC, this would mean the BCBA may be unable to bring in revenue to support their continued employment. Though this may be a very unwanted outcome for all parties, it is important the employers have this information so they can ensure their clients/families can continue care with a licensed and credentialed provider who is able to provide services within their available resources (i.e. insurance-paid treatment).

Considerations for Explorations:

• As the Ethics Code states, BCBAs should remain knowledgeable of requirements from governing entities (funders) and should self-report where relevant.  This should include reporting any fraudulent billing, criminal history or investigations that should be disclosed to the BACB, AZ Board of Psychologist Examiners and funders with which they are attempting to credential.  The Ethics committee believes the BCBA should self-report where necessary to ensure all licensing bodies are aware of any complaints to avoid future misconduct.

Applicable Ethics Codes and ARS (identified by the committee)

• 2.06 Accuracy in Service Billing and Reporting
• 1.01 Being Truthful 
• 1.02  Conforming with Legal and Professional Requirements
• 1.16 Self-Reporting Critical Information
• ARS 32-2091 12. "Unprofessional conduct" includes the following activities, whether occurring in this state or elsewhere: Obtaining a fee by fraud or misrepresentation.
• ARS 32-2091 12(e) Gross negligence in the practice of a behavior analyst.
• ARS 32-2091 12 (k) Violating any federal or state law that relates to the practice of behavior analysis or to obtain a license to practice behavior analysis.
• ARS 32-2091 12 (n) Unprofessional conduct in another jurisdiction that resulted in censure, probation or a civil penalty or in the denial, suspension, restriction or revocation of a certificate or license to practice as a behavior analyst.
• ARS 32-2091 12 (v) Abandoning or neglecting a client in need of immediate care without making suitable arrangements for continuation of the care.

Additional Resources:

• OIG: https://exclusions.oig.hhs.gov/