Submission:
I am an RBT in a clinic setting. Recently, we have had too many clients and not enough staff. As a result, the clients are scheduled for group ABA sessions with other clients to fill the necessary gaps. Clients are grouped together for clinic ease rather than by program fit. I wanted to reach out to see if this is a potential ethical violation. The staff that are providing group therapy services often have not been trained on how to run group sessions and there is limited support because analyst trainees have also been utilized for direct sessions frequently.
We have RBTs that are creating the schedule at the moment. The RBTs make the direct therapy sessions for everyone that provides direct services.
Committee Input (e.g., considerations for pathways forward, potential barriers, potential solutions):
First, in addition to compliance with all CPT® code descriptions, services rendered must be based on the individual medical necessity needs of the person receiving services. Group services are an excellent practice to ensure natural contingencies are being trained and supervised. These services should only be rendered to benefit the client to include appropriate pairing, supervision, compliance with the treatment plan, and observation to allow for quick changes if the setting or pairings are not good fits. Under no circumstance should grouping happen in the event that staff is not trained, or pairings are not appropriate, solely to aid the company with staffing issues. Children receiving group ABA must receive the same amount of diligence for setting targeted group goals, data collection, and treatment planning.
Additional concerns of group billing include (1) this may encourage the business to inflate the requested medically necessary service units needed to be able to bill for things that are otherwise non-billable, which includes billing for a service that is not indicated or appropriate as a medical necessary service, like pairing children who do not have the same type of goals, (2) engaging in this practice they may be potentially taking away opportunity for medically necessary sessions that should be provided directly to your client with proper pairings and goals, (3) the organization response appears to indicate that this is occurring as a standard of practice across multiple clients. This may leave many vulnerable individuals and their families without access to medically necessary ABA services should their benefits be exhausted. If the service is not meeting medical necessity standards and is instead serving the need of childcare, no medical billing should be occurring.
In accordance with Ethics Codes 1.03, 2.01, 2.06, 2.14, 2.16, 2.19, 3.01, 4.01, 4.04, and 4.06, the committee recommends that the author reach out to the overseeing BCBA(s) in question to advocate for the level of supervision of technicians and clients that is commensurate with ethical standards. The committee would encourage the author to explore the following steps as options; this should not be considered legal employment advice:
1. Write a formal letter to your supervisor and to the executive administration, including HR, educating them on and outlining our ethical codes of conduct surrounding RBT supervision and training, caseload size, and accuracy in service billing and reporting. Provide suggestions to them on ways in which they can support BCBAs in your agency that are more conducive to best practices in supervision and quality care for clients.
a. Documentation of concerns can provide you protection against wrongful termination and provides a clear statement for follow-up. It also demonstrates action on your part following the identification of an ethical concern, safeguarding your license and ability to practice.
2. If meaningful change is not made to satisfy the ethical code of conduct, the BCBA should send their letter to the ethics committee at the BACB and/or the Arizona State Licensure Board and follow complaint guidelines.
It is the responsibility of the Licensed Behavior Analyst 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. Practitioners who are unable or unwilling are subject to BACB and AZBoPE disciplinary action.
Considerations for exploration:
The committee acknowledges that any breach in the BACB Ethics Code is reportable to the Arizona State Licensure Board. The Committee would encourage the reportee to explore filing a complaint with the licensure board, against the party in the organization who is inappropriately allowing clients to be put into groups that are not otherwise indicated. supervising a client, if mediation using other, more informal methods does not yield an improved result.
● Information on the complaint process can be found here: https://psychboard.az.gov/investigations
If resolution cannot be achieved, the author may need to explore ethical and values-aligned employment opportunities.
● While the BCBA has a responsibility to provide adequate supervision for a client, they are also responsible for providing adequate supervision for the RBTs they oversee. If this BCBA is overseeing RBTs, it is advised that the RBT ensure appropriate documentation of supervision is available to them.
Ethics Codes (specific standards that could apply to support/oppose):
● 1.03 Accountability
● 2.01 Providing Effective Treatment
● 2.06 Accuracy in Service Billing and Reporting
● 2.14 Selecting, Designing, and Implementing Behavior-Change Interventions
● 2.16 Describing Behavior-Change Interventions Before Implementation
● 2.19 Addressing Conditions Interfering with Service Delivery
● 3.01 Responsibility to Clients
● 4.01 Compliance with Supervision Requirements
● 4.04 Accountability in Supervision
● 4.06 Providing Supervision and Training
● ARS 32-2091.12(e),(o)
