Potential Violation of Ethics Code: Double Billing Concern from Providers  

Relevant background: “When approving session notes for my child's ABA, I noticed what looked like double billing. Both the newly assigned BCBA and the student analyst (who has been the primary case manager) submitted sessions for the same parent meeting. This meeting did occur, but it is my understanding that only one of them should be billing 97156 for this appointment. However, they both have billed the same code for the same time and date. When I reached out to the organizations billing department, this was the response "They can when one is shadowing, it happens quite often.  And as long as our billed units stay within what our authorization is for, it has not been a problem with Insurances.”

Possible solutions: “I am looking for confirmation either way before proceeding as I do not feel comfortable signing off these sessions.”

Credentialing: N/A, reporter is a consumer

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

Disclaimer: The following guidance is based on relevant experience and resources and may differ by payor. This guidance is not intended as legal advice.

It may be important to consider circumstances in which multiple appointment notes may be submitted to the family for documentation, but billing may only be completed by one provider.  To verify what has been submitted to your funder, review your Explanation of Benefits (EOB) documentation (commercial insurance) to confirm if duplicate billing was submitted. The student analyst model is only allowable in Arizona for AHCCCS plans. AHCCCS plans are not required to supply EOBs, therefore families are recommended to contact member services on the back of your insurance card for specific claim information.

If both appointments are indeed being billed to your insurance plan, this is an unacceptable use of 97156. Under both the American Medical Association (AMA) CPT® coding description, as well as the National Correct Coding Initiative (NCCI) policy, 97156 is to be billed when a single provider is rendering a service.

In addition to compliance with all CPT® code descriptions, services rendered should be based on the specific medical necessity needs of the individual receiving the services. Services such as shadowing, training, and employee supervision are considered organizational costs and not allowable justifications for billing any of the CPT® codes to a payor. 

Therefore, the agency’s statement that it’s acceptable as long as it falls within the authorization is misaligned with policy and legal considerations associated with health plan’s prior authorization processes and therefore may be a direct violation of their payor contract. Additional concerns include speculation that the business is inflating hour requests to cover non-billable activities and/or that the business is taking away the opportunity for medically necessary sessions that are available to the family.

It is the responsibility of the Licensed Behavior Analyst (assigned as your provider) to ensure compliance with appropriate use of the CPT® codes, as outlined by the payor contract, AMA, CMS and NCCI. Regardless of the organization policies, the Licensed Behavior Analyst, through their provider agreement to participate in a health plan, must comply with all applicable state and federal laws.

We recommend that the reportee review ARS 32-2091.12 which outlines, “Unprofessional Conduct” to include:

·        (a) Obtaining a fee by fraud or misrepresentation;

·        (e) Gross negligence in the practice of a behavior analyst; 

·        (o) Providing services that are unnecessary or unsafe or otherwise engaging in activities as a behavior analyst that are unprofessional by current standards of practice.

Considerations for Explorations: 

It’s recommended that the reportee consider taking the following actions:

• 1.      As the client representative/caregiver, consider declining consent to allow for the duplicate billing.
• 2.      Consider gathering additional consumer documentation available to you as it relates to any other potential concerns related to duplicate billing (i.e., EOB, member services) to determine the extent to which this has occurred.
• 3.      Report the concern and/or any additional findings directly to your child’s specific health plan’s Fraud, Waste and Abuse Hotline as soon as possible. This can be done anonymously.
• 4.      If after you have gathered sufficient information to determine that a violation has occurred, consider filing a complaint with the Arizona Board of Psychologist Examiners. 

Applicable BACB® Ethics Codes and Arizona Revised Statute (identified by the committee)

BCBA® Codes:

1.02 Conforming with Legal and Professional Requirements

2.01 Providing Effective Treatment

2.06 Accuracy in Service Billing and Reporting

2.07 Fees

3.01 Responsibility to Clients

3.05 Financial Agreements

3.12 Advocating for appropriate services

ARS:

ARS 32-2091.12 (a) (e) (o)