Preparing Your ABA Company for a Payor Audit

aba-therapist-play-therapy-young-boy-e1690574727628Our healthcare and business law firm works with many behavioral health providers in establishing and operating their ABA associated businesses.  We have a particular focus on such companies and will be producing a series of helpful articles to assist providers in navigating various operational and business hurdles to ensure they are able to effectively treat their patients.

If you have questions regarding this blog post or would like to speak with counsel regarding opening your medical spa practice, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, You may also learn more about our law firm by visiting


Payment and claims audits for ABA providers are becoming increasingly more common given the rising number of patients being cared for with autism and related disorders. For most ABA providers, an audit is no longer a probability but a certainty. Audits are frequently stressful for an owner of an ABA practice, regardless of size, but smaller practices may not have the resources to deal with the additional requests by auditors when one occurs.  However, by taking proactive steps, ABA providers can position themselves in the best possible way to defend against significant reimbursement demands, prepayment review, contract termination, and/or criminal fraud investigations.

When is an audit triggered?

Health insurance companies (including Medicaid), frequently utilize audits to ensure that all clinical and billing requirements in your provider contract and their provider manual are met. While some audits are simply routine in nature, others may be triggered as a result of things such as: outlier payments, higher-than-average utilization rates, increases in treatment or supervision hours, billing a new procedure code or location (home, center-based, remote), complaints from employees or patients, previous errors or problems on past audits or simply random provider selection.

What information is requested?

In most cases, payors request primary source data such as patient medical records on a selected sample of patients and dates of service.  For those ABA providers who have an EMR system, producing the requested documentation can often be an easier task than those relying solely on paper records which may be more challenging to collect and produce. These records are then reviewed in accordance with the payors’ billing policies and procedures, many of which won’t be found in your provider contract but rather deeply imbedded in the payors’ reimbursement manual.  Depending upon the level of errors identified, the payor may request a finite dollar amount be returned or they may extrapolate the results to the ABA provider’s entire universe of patients whose care is financed by the payor for the applicable time period. Because of payor reliance on extrapolation, adverse findings with respect to even a single claim can have a significant effect on payor demands for recoupment.

What are the most common audit findings?

During the audit, payors are looking for clear documentation to evaluate whether the ABA provider’s records justify the claims submitted for reimbursement.  In most instances, audit findings fall within the following general categories: (1) inadequate documentation (missing therapist or caregiver signatures, dates not provided); (2) billing irregularities (billing for group therapy, overutilization of supervision hours); (3) missing or expired provider credentials; and (4) improper billing codes.

 How do I respond to a payor audit?

When you receive a payor audit the following is recommended:

  • Do not ignore the request. Calendar the deadline and don’t miss it.
  • Review the request carefully and assign someone to be the point person for collecting the data.
  • Consult your provider contract and provider manual.
  • Assemble a complete record and review it completely before sending.
  • Consider adding an explanatory letter if the medical records are not complete.
  • Keep a copy of the package you submit.

What happens when I get an audit finding and the payor requests a refund?

Payor audits are usually not about the quality of care given, but rather about the quality of the records kept. Given the nature that most medical record documentation is maintained, it is likely that payors will find that some records do not meet their documentation requirements and request a refund. At that time, you will need to carefully consider whether an appeal will be justified.  If you believe that information may have been overlooked or that your initial submission was missing documentation you will need to appeal the decision within the time frame set out by the payor.  At this time, it is highly recommended that you speak with counsel skilled in payor contracting and payor appeals to assist you.  A misstep at this stage may not only cost you thousands of dollars but also subject you to future payor audits or severe reputational damage.

How can I be proactive in avoiding payor audits and recoupment requests?

  • Be familiar with the rules and requirements that each payor expects providers to follow. Use resources such as the provider agreement, provider manual and any guidance or payment determinations that the payor has published.
  • Conduct internal self-audits such as medical chart reviews to ensure that you are complying with each payor’s rules and requirements for record keeping and billing.
  • Make sure your company has a policy in place for how to respond to any audit requests and ensure that all employees are trained accordingly.

If you have questions regarding this blog post or would like to speak with counsel regarding your ABA and behavioral health business, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, You may also learn more about our law firm by visiting

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