100% Of Audited Medicaid Claims For Autism Care In Colorado Were Improper Or Flawed: Report

Authored by Sylvia Xu via The Epoch Times (emphasis ours),

Colorado’s Medicaid program made an estimated $77.8 million in improper payments and another $207.4 million in potentially improper payments for autism therapy, according to a February report from the Inspector General for the Department of Health and Human Services.

Auditors investigated $289.5 million in Medicaid payments from 2022 to 2023 that paid for more than 1 million claims for Applied Behavior Analysis—a therapy used to treat autism and developmental disabilities.

Each of the 100 claims reviewed contained at least one improper or potentially improper payment, suggesting a 100 percent failure rate.

Improper payments are not necessarily fraudulent. Payments are considered improper when the claim does not meet federal or state requirements. Payments are potentially improper when the submitted claim is so poor or unreliable that auditors cannot verify that the services were provided correctly.

Claim Errors

In 93 of 100 claims examined, the billing providers either did not provide notes verifying that the therapy took place, didn’t provide the required signatures, or billed for more time than the notes indicated.

In 18 cases, the therapy that was supposed to be performed by a specialist—such as a Board Certified Behavior Analyst—was performed by staff without those qualifications.

In seven cases, the children receiving therapy lacked a current doctor’s diagnosis or referral on file.

In 88 cases, facilities billed for recreational activities that are not considered medical therapy, such as academic tutoring, day care, or custodial care. In one case, a facility billed for children swimming and playing on water slides.

In 76 cases, facilities billed for a full eight-hour day without subtracting time for naps, meals, or breaks.

Oversight and Safety Concerns

The report concludes that Colorado made these improper payments because it did not provide effective oversight. The state did not regularly review Medicaid payments to catch errors and failed to give clear guidance to therapy centers on how to bill or what counts as therapy.

Additionally, the state didn’t properly check if its prior authorization contractors were following the rules when approving therapy for children.

While the audit focused on money, it also uncovered problems that could affect the safety and quality of care.

Some staff members had criminal convictions for weapons offenses, assault, or driving under the influence. In one case, three staff members at a facility providing care to an 11-year-old child with autism had criminal histories.

A non-credentialed technician had a felony weapons offense conviction three months prior to treating children. A registered behavior technician had been convicted of misdemeanor assault and physical harassment, such as a strike, shove, or kick. Another behavior technician had an aggravated misdemeanor weapons conviction.

The state did not require background checks for these workers.

Previous Audits

The report comes as part of a series of seven Inspector General audits examining state Medicaid payments for autism therapy. Four are are complete and three remain in progress.

In previous audits, the agency estimated more than $120 million in improper payments and nearly $200 million in potential improper payments for Indiana, Wisconsin, and Maine.

The potential fraud, waste, and abuse in Medicaid autism therapy payments in Colorado was the highest among these audits.

The Office of Inspector General recommended that Colorado refund $42.6 million—the federal portion of the improper payments—to the federal government.

Also, the agency suggested that the state begin regular reviews of autism facilities to ensure they follow the rules and provide better training and guidance to facilities on documenting and billing for therapy.

The state of Colorado agreed to improve its guidance and conduct more regular reviews in the future, according to a statement. But it disagreed with the recommendation to refund the money, arguing that the audit derived its findings from a limited sample and didn’t have enough detail on the errors.

Further, Colorado argued that its Medicaid program does not require certification of behavior technicians before making payments, so the refund calculation based on this statute should be rescinded.