Autism Care Demonstration: Compliance, Audits and Keys to Success

Tuesday, August 17, 2021

Applied behavior analysis (ABA) providers must comply with medical documentation and billing practices listed in the TRICARE Operations Manual (TOM), Chapter 18, Section 4; state and federal regulations; and provider participation agreements, policies and guidelines at all times. Providers who fail to demonstrate compliance are subject to additional training, payment recoupment, penalties, and/or more severe administrative actions as required by law and contract.

Health Net Federal Services, LLC (HNFS) reviews provider billing practices to verify services ABA providers bill TRICARE for are:

TRICARE-approved services under the Autism Care Demonstration (ACD).
Supported by clear and complete progress notes (medical documentation).

Please familiarize yourself with the types of reviews and guidelines. Find additional details on our Compliance and Audits web page.

Keys to success

Become familiar with TOM, Chapter 18, Section 4 requirements.
Document all required elements in progress notes.
Ensure claims billed are supported by corresponding medical documentation.
Provide services in line with adapted behavior services (ABS) approved CPT code definitions.
Avoid exclusions.

Audit types and frequency

As of Aug. 1, Autism Corporate Services Provider (ACSP) groups and sole ABA providers are subject to a minimum of 30 record reviews annually. These include administrative and medical documentation reviews, and a review of one medical team conference progress note, if available.

Separately and on an ongoing basis, HNFS reviews CPT® code billing practices of ABA providers to ensure compliance with TOM requirements.

CPT code reviews: Review of claims billed to verify services were rendered as required, such as CPT 97155 rendered by the ABA supervisor once per month.
Administrative reviews: Using anti-fraud software, review of claims data to identify and prevent potentially fraudulent billing practices.
Medical documentation reviews: Review of medical records to ensure claims are supported by corresponding medical documentation, documentation requirements are met, and no exclusions were rendered during the session.

Medical documentation review notification

HNFS will contact providers ahead of all medical documentation reviews. Please use this time to ask any questions you may have about the process. Once you receive our written request for documentation, be sure to return the requested medical records by the due date specified. Records not received by the due date will negatively impact the audit score.

New medical documentation requirements

Some key updates to pay attention to as of Aug. 1: TRICARE requires progress notes (also referred to as session notes) to include the location of rendered services, name of the authorized ABA supervisor and name of all session participants. Additionally, documentation for medical team conference CPT codes 99366 and 99368 must include the participants’ roles in the conference, contributions during the conference and subsequent treatment recommendations.

Reviews for new providers

As of July 1, HNFS monitors all new network and non-network ACSPs/sole ABA providers during their initial 180 days of TRICARE West Region participation. The 30 annual audits frequency does not apply to new providers. Following the 180 days, we will review a minimum of 10 records for clinical documentation and claims submission for consistency with program. We will share results with new providers, and if necessary, provide education to address inconsistencies with program requirements.

Review findings

After completing the review, we will send a written summary to the provider. We may assign online training that targets errors identified in the audit. Additional action may include but is not limited to probe audit, prepayment review and/or referral to HNFS’ Program Integrity department.