Melissa L. Olive, PH.D., BCBA-D Applied Behavioral Strategies, LLC

Melissa L. Olive, Ph.D.
, BCBA-D
Applied Behavioral Strategies, LLC

Ethical Issues in Billing MassABA 5.4.17
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•Melissa Olive Applied Behavioral Strategies LLC 2
 Effective July 1, 2008 BACB initially required 3

Type 2 hours required in Ethics (and professional
issues)
 Currently, 4 hours are required and professional
issues no longer allowed under Ethics
 Acceptable ethics content is behavior-analytic in
nature and covers ethical issues in behavior
analysis practice or research.
 Ethics content should incorporate the
BACB’s Ethics requirements.
 Billing fraud is one of the biggest ethical
concerns facing behavior analysts
Applied Behavioral Strategies LLC 3
 Participants will describe how the current BACB Professional and

Ethical Compliance Code applies to providing and billing for ABA
services
 Participants will describe key components of HIPAA and HITECH
and how they relate to providing and billing for ABA services
 Participants will describe relevant policies from the Centers for
Medicaid and Medicare
 Participants will describe the relevant CPT coding rules that apply
 Participants will describe the appropriate use of new and old CPT
codes
 Participants will identify strategies for prevention of billing fraud
info@appliedbehavioralstrategies.com;
Melissa L. Olive, Ph.D., BCBA-D 1
1. What must you know as a BCBA?

2. The Code
3. HIPAA and HITECH
4. CMS Rules
5. New Codes (ABAI and AMA documents)
6. Old Codes
7. Software to Assist You
8. Strategies for Preventing Fraud
9. Questions and Discussion Throughout
 Bailey, J.S. & Burch, M. R. (2005). Ethics for

behavior analysts: A practical guide for
responsible conduct. Lawrence Erlbaum
Associates: Mahwah, New Jersey.
 2nd edition (2011)
 Third Edition (2016)
 (a) Behavior analysts are truthful and honest and

arrange the environment to promote truthful
and honest behavior in others
 (b) Behavior analysts do not implement
contingencies that would cause others to
engage in fraudulent, illegal, or unethical
conduct
 (c) Behavior analysts follow through on
obligations, and contractual and professional
commitments with high quality work and refrain
from making professional commitments they
cannot keep
 (a) Behavior analysts provide behavior-

analytic services only in the context of a
defined, professional, or scientific
relationship or role.
 No drive-by ABA!
 (a) Due to the potentially harmful effects of multiple

relationships, behavior analysts avoid multiple
relationships.
 (b) Behavior analysts must always be sensitive to the
potentially harmful effects of multiple relationships. If
behavior analysts find that, due to unforeseen factors,
a multiple relationship has arisen, they seek to resolve
it.
 (c) Behavior analysts recognize and inform clients and
supervisees about the potential harmful effects of
multiple relationships.
 (d) Behavior analysts do not accept any gifts from or
give any gifts to clients because this constitutes a
multiple relationship.
 1.07 Exploitative Relationships. RBT
2.01 Accepting Clients. (definition of client)

2.02 Responsibility. RBT
2.03 Consultation
 (a) Behavior analysts arrange for appropriate
consultations and referrals based principally
on the best interests of their clients, with
appropriate consent, and subject to other
relevant considerations, including applicable
law and contractual obligations.
 2.04 Third-Party Involvement in Services

▪ Clarify the nature of services at the outset
▪ Clarify the nature of the relationship with each
party and any potential conflicts
▪ If a risk exists for conflicting roles, clarify, keep
everyone informed, and resolve
▪ Providing services to minors or protected
populations (keep parents/guardians informed)
▪ Put the client’s care above all others
 2.05 (a)The rights of the client are

paramount and behavior analysts support
clients’ legal rights and prerogatives
 2.06 Maintaining Confidentiality
 2.07 Maintaining Records
 2.09 Disclosures
 2.10 Documenting professional work &
research
 2.11 Records and fees
 2.12 Contracts, Fees, and Financial

Arrangements
 Signed contract
 Specify compensation and billing
arrangement
 Fee practices
 Revisit funding with client if it changes
▪ Insurance policies are ever changing!
 Behavior analysts accurately state the nature

of the services provided, the fees or charges,
the identity of the provider, relevant
outcomes, and other required descriptive
data.
 (a) If behavior analysts believe there may be a legal or ethical violation, they first
determine whether there is potential for harm, a possible legal violation, a mandatory-
reporting condition, or an agency, organization, or regulatory requirement addressing
the violation.
 (b) If a client’s legal rights are being violated, or if there is the potential for harm,
behavior analysts must take the necessary action to protect the client, including, but not
limited to, contacting relevant authorities, following organizational policies, and
consulting with appropriate professionals, and documenting their efforts to address the
matter.
 (c) If an informal resolution appears appropriate, and would not violate any
confidentiality rights, behavior analysts attempt to resolve the issue by bringing it to the
attention of that individual and documenting their efforts to address the matter. If the
matter is not resolved, behavior analysts report the matter to the appropriate authority
(e.g., employer, supervisor, regulatory authority).
 (d) If the matter meets the reporting requirements of the BACB, behavior analysts
submit a formal complaint to the BACB. (See also, 10.02 Timely Responding, Reporting,
and Updating of Information Provided to the BACB)
 Health Insurance Portability and

Accountability Act of 1996
 The Health Information Technology for
Economic and Clinical Health (HITECH) Act,
enacted as part of the American Recovery
and Reinvestment Act of 2009
▪ Penalties and enforcement
 Health Care Plans

 Clearinghouses
 Any health care provider who transmits
health information in electronic form in
connection with transactions (billing,
authorizations, etc)
 The Privacy Rule protects all "individually

identifiable health information" held or
transmitted by a covered entity or its
business associate, in any form or media,
whether electronic, paper, or oral
1. Individual (or guardian)

2. Treatment, Payment, Healthcare
3. Approved Use (e.g., pharmacy)
4. Incidental Use
5. Public Interest
6. Limited Data Set
 Written consent
 Each covered entity, with certain exceptions,

must provide a notice of its privacy practices
 A covered health care provider with a direct
treatment relationship with individuals must
make a good faith effort to obtain written
acknowledgement from patients of receipt of
the privacy practices notice.
 Access
 Amendment
 Disclosure Accounting
 Restriction Request
 Confidential Communications Requirements
 How “we” must protect privacy

 Applies to Electronic PHI
 We must:
1. Ensure confidentiality
2. Protect against threats or hazards
3. Protect against disclosures
4. Ensure compliance by employees
 Enforceability
 Also applies to business associates (e.g.,
cleaning crew)
 Increased the penalties from $100 per
violation to $50,000 maximum
 Did not know ($100-$50,000 per incident)

 Reasonable Cause ($1,000-$50,000)
 Willful Neglect-Corrected ($10,000-$50,000)
 Willful Neglect-Not Corrected ($50,000)
Different confidentiality rules apply
 NPI Number
 CAQH Registry
 Getting “in network”
 State by state
 Sometimes region by region
 State funding opportunities
▪ Waivers
▪ Grants
▪ Other funding
 https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/index.html
 https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/downloads/
R2121CP.pdf
 The most important form

 https://www.cms.gov/Medicare/CMS-
Forms/CMS-Forms/Downloads/CMS1500.pdf
 The way it used to be

 Insurance legislation
 Each carrier developed codes
 2014 AMA developed T codes
 Carriers began moving over to T codes
 UBH still uses H codes
 ABAI documents
 AMA documents
 Trainings, meetings, conferences, reading
 Assessment
1. Behavior Identification
2. Follow Along (probe)
3. Functional analysis
 Assessment
1. Behavior Identification 0359T
2. Observational Follow Up 0360T (first 30 min)
3. Observational Follow Up 0361T (additional
30 min)
4. Exposure Behavioral Follow Up (Functional
Analysis) (first 30 min)
5. Exposure Behavioral Follow Up (Functional
analysis) (additional 30 min)
 Treatment
1. Treatment by protocol
2. Group Treatment by protocol
3. Functional Analysis/Component Analysis
 Treatment
1. Treatment by protocol (0364T & 0365T)
2. Group Treatment by protocol (0366T &
0367T)
3. Functional Analysis/Component Analysis
(0373T and 0374T)
 BCBA Activities
1. Assessment & Treatment Planning
2. Developing & Modifying Treatment
3. Family Guidance
4. Group Family Guidance
5. Social Skills
 BCBA Activities
1. Assessment (0359T, 0360T, 0361T)
2. Developing & Modifying Treatment (0368T
& 0369T)
3. Family Guidance (0370T)
4. Group Family Guidance (0371T)
5. Social Skills (0372T)
http://www.dodig.mil/pubs/documents/DODIG-2017-064.pdf
 Listening to people on Facebook

▪ Instead…..go to the original source
 Billing for BCaBA as the Qualified Practitioner
▪ Read the contract with carrier
▪ Does not follow CPT definitions
▪ Know state law for license if it exists
▪ It does, however, follow the crosswalk definition
 Billing for indirect time
▪ Follow the 8 minute rule
▪ Use remaining time for paperwork
▪ TRAIN staff to follow the rules
 H0046
 H0031
 H0032
 H2012
 H2019
 G 9012
 Too many to list!
 Does it play nicely with others?

▪ Google?
▪ Quickbooks?
▪ Gateway (or other clearinghouse)
 Does it have fingerprinting?
 Locking capability
 Attestation capability
 GPS capability
 Appropriate rounding or non-rounding
 Appropriate certifications for the service
 “Bundling” of codes
 Start and stop time
 Session notes
 Other relevant paperwork
 On site rendering
 Therapist signature
 Parent signature
 Locking & attesting 2 times per month
 Verifying 2 times per month with service logs
 Parents sign service logs
 Supervisor lock
 Cross checking of time cards when
appropriate
 Supervisor note
 Therapist note on data sheet regarding
supervisor
 BCBA monitoring by senior staff
▪ Monitor for billables
▪ Monitor for clinicals
1. HIPAA Training
1. Keep your mouth shut
2. Avoid social media
3. Need to Know
4. Written Consent (at all times!)
5. Risk Analysis (not the one described by Bailey and
Burch)
2. Training Attestation
3. Ethics Cases each month
4. Mentor meetings
5. Quality control

Melissa L. Olive, PH.D., BCBA-D Applied Behavioral Strategies, LLC

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Melissa L. Olive, Ph.D.

Applied Behavioral Strategies, LLC

•Follow the blog:

 Effective July 1, 2008 BACB initially required 3

 Participants will describe how the current BACB Professional and

Applied Behavioral Strategies LLC 4

1. What must you know as a BCBA?

 Bailey, J.S. & Burch, M. R. (2005). Ethics for

Applied Behavioral Strategies LLC 6

 (a) Behavior analysts are truthful and honest and

 (a) Behavior analysts provide behavior-

Applied Behavioral Strategies LLC 9

 (a) Due to the potentially harmful effects of multiple

 1.07 Exploitative Relationships. RBT

Applied Behavioral Strategies LLC 11

2.01 Accepting Clients. (definition of client)

 2.04 Third-Party Involvement in Services

 2.05 (a)The rights of the client are

 2.12 Contracts, Fees, and Financial

Applied Behavioral Strategies LLC 15

 Behavior analysts accurately state the nature

Applied Behavioral Strategies LLC 16

Applied Behavioral Strategies LLC 17

 Health Insurance Portability and

Applied Behavioral Strategies LLC 20

 Health Care Plans

Applied Behavioral Strategies LLC 21

 The Privacy Rule protects all "individually

Applied Behavioral Strategies LLC 22

1. Individual (or guardian)

Applied Behavioral Strategies LLC 23

Applied Behavioral Strategies LLC 24

 Each covered entity, with certain exceptions,

Applied Behavioral Strategies LLC 25

Applied Behavioral Strategies LLC 26

 How “we” must protect privacy

Applied Behavioral Strategies LLC 27

Applied Behavioral Strategies LLC 28

 Did not know ($100-$50,000 per incident)

Applied Behavioral Strategies LLC 29

Different confidentiality rules apply

Applied Behavioral Strategies LLC 30

Applied Behavioral Strategies LLC 32

Applied Behavioral Strategies LLC 33

 The most important form

Applied Behavioral Strategies LLC 34

 The way it used to be

Applied Behavioral Strategies LLC 36

Applied Behavioral Strategies LLC 37

Applied Behavioral Strategies LLC 38

Applied Behavioral Strategies LLC 40

Applied Behavioral Strategies LLC 41

Applied Behavioral Strategies LLC 42

Applied Behavioral Strategies LLC 43

Applied Behavioral Strategies LLC 45

 Listening to people on Facebook

Applied Behavioral Strategies LLC 46

Applied Behavioral Strategies LLC 47

 Too many to list!