Portal Submission:
I have encountered a situation where I believe there is fraudulent billing, or at least untruthful behavior. The situation consists of RBTs billing for services that they are not present for (typically for 30 minutes) and other RBTs were billing under names that were not their own. For example, RBT 1 has Client 8:30- 12:00 on their schedule and will bill for this entire time. However, RBT 1 is only present from 8:30 – 11:30. RBT 2 comes in with the client 11:30- 12:00. At the end of the day, RBT 1 writes their billing note as if they were present from 8:30-12:00. Nowhere in the record is it stated that RBT 2 took over for any duration of time. (1.01 Being Truthful, 2.06 Accuracy in service billing and reporting).
I have brought this up to my supervisor and the chief of staff at the company I work for. Both are BCBA's. I was told not to worry about it and that there is no ethical violation and that the BCBA has done this at other companies. I am still not comfortable with this practice, so I am not having any RBTs that I supervise engage in this behavior. However, I know it is still being conducted across the company in their other locations. I was told that because the BCBA cosigns the note that it doesn't matter what RBT is present for the services and that it can be all billed under one regardless of if they were not present for 30 minutes of the time they are billing for.
Committee Input (e.g., considerations for pathways forward, potential barriers, potential solutions):
Under no circumstances is it permissible that an RBT or BCBA bill any CPT codes that they were not present for. The Centers for Medicare and Medicaid Services (CMS) defines fraud as “intentionally submitting false information to the Government or a Government contractor to get money or a benefit.” Based on the description provided it is possible, if not likely, that fraud is occurring. Additionally, when an RBT or BCBA signs a session note that contains purposeful/intentionally inaccurate information, they are falsifying medical records.
It is the responsibility of the supervising Licensed Behavior Analyst to ensure compliance with appropriate use of the CPT® codes, as outlined by the payor contract, American Medical Association, CMS and National Correct Coding Initiative (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 to align with applicable laws are subject AZBoPE and BACB disciplinary action.
The committee commends the reportee on identifying that these practices are unethical. It is important to note that most provider contracts, as well as 32-2091, require any licensed behavior analysts who becomes aware of, or suspects, fraudulent activity to report such activity to the appropriate regulatory organization (i.e. funder, AZBoPE).
As a Licensed Behavior Analyst, you are now required to take further steps to either educate or hold others accountable for their behavior.
Considerations for exploration:
In accordance with Ethics Codes 1.01, 1.02, 1.03, 2.06, 3.11, and 4.04, the committee recommends that the author attempt again to reach out to the overseeing BCBA(s) in question to discuss their concerns, if it is safe to do so and it is likely that a resolution can be reached. It may be unlikely based on your description of events that a change in behavior will occur. The committee would encourage the author to explore the following steps as options; this should not be considered legal employment advice:
1. If you have not already done so, 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 accuracy in service billing and reporting.
a. Documentation of your 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 LBA should consider following the complaint guidelines for the Arizona State Licensure Board. The Committee would encourage the reportee to explore filing a complaint with the licensure board against the licensed behavior analyst in the organization who is supervising the inappropriately billing, and/or engaging in the inappropriately billing themselves if mediation using other, more informal methods does not yield an improved result.
a. Information on the complaint process can be found here: https://psychboard.az.gov/investigations
3. Report the concern and/or any additional findings directly to the payor or health plan’s Fraud, Waste and Abuse Hotline as soon as possible. If multiple health plans are involved, a single report to the AHCCCS Fraud Waste and Abuse portal, or the Arizona Attorney General’s office can be made. This can be done anonymously.
4. If resolution cannot be achieved, the author may need to explore ethical and values-aligned employment opportunities.
Ethics Codes (specific standards that could apply to support/oppose):
● 1.01 Being Truthful
● 1.02 Conforming with Legal and Professional Requirements
● 1.03 Accountability
● 2.06 Accuracy in Service Billing and Reporting
● 3.11 Documenting Professional Activity
● 4.04 Accountability in Supervision
● ARS 32-2091.12(a), (e), (z),
