By Dan Matas, Founder of OutcomesBase, Inc.
In the field of Applied Behavioral Analysis (ABA), Regulatory Compliance can sometimes be an afterthought. Often, companies may not understand what all is encompassed by the term 'regulatory compliance' or there may be a lack of resources that allow for a company to focus on compliance endeavors.
In simple terms, regulatory compliance is the adherence to state laws, federal laws, and payor requirements that are in place for companies who provide ABA services. Compliance is a difficult area to get right, but failure to do so can have big impacts on a company's ability to submit clean claims, ensure payment for services rendered, and avoid future clawbacks. When discussing Compliance, I like to focus on three key areas: Clients, Contracts, and Cost.
Clients
The main reason that compliance is important is because it focuses on the clients and the services that they are receiving. I've worked in this field long enough to know that BCBAs care about ethics and providing high-quality services. ABA isn't a glamorous field, but it is a service with a growing need and many clients and families are benefitting from it daily.
Where compliance and clients intersect, is in the ethics of service delivery. To ensure ethics, it's important to maintain the following: clients are being prescribed the correct levels of care for their medically necessary services, the services being delivered are focused on clinical programming and avoid anything that could be considered babysitting, and services are being properly documented as far as what occurred during the treatment and how the client responded.
By demonstrating strong ethical values in service delivery, clients receive better quality of care and the payors are more satisfied with the providers.
Contracts
Each payor contract has established requirements and regulations that they expect ABA companies to follow during the intake of new clients, throughout client treatment, and during the discharge of services. A failure to follow these items could not only damage relationships with payors and future referral-sources, but they can impact revenue that has already been collected if not adhered to.
All insurance companies are regulated by the federal government, and all Medicaid insurance companies are also governed by individual States in which they preside and by the Center for Medicare and Medicaid Services (CMS). This means that the government and CMS are actively auditing and monitoring insurance companies to ensure that they are operating correctly in accordance with the laws. In turn, each insurance company is responsible to ensure that the providers that it contracts with are also following all of the requirements and regulations in accordance with the law.
Many of the more established insurance companies, and most Medicaid programs, audit their providers on a regular basis. ABA companies that perform well on audits may be able to avoid more intrusive annual audits, while those who perform poorly are subject to corrective action plans (CAPs) and may be required to pay back revenue that was previously collected. The government tracks all recoupments annually and insurance companies love to boast about the funds they re-collected due to providers not properly understanding the requirements.
Maneuvering through contract requirements may be the most tricky component of regulatory compliance as each payor, each state, and the government, may have conflicting and/or very different requirements. Creating a system for tracking these regulations, keeping up-to-date with changes, and understanding these regulations is key to compliance in all ABA companies.
Cost
Although most ABA companies cannot afford to hire a dedicated Compliance Officer, or Compliance Department, working to establish a Compliance program is vital and will reduce costs in the future. Every HIPAA breach, every failed audit, and every breached contract, can result in hefty fees or costs to an organization. Insurance companies are pretty ruthless when it comes to clawing back funds and they have dedicated teams who work to investigate claims data and recoup as much payment as possible. From my experience working with them, I wouldn't be surprised if those teams get a nice bonus when they find and execute a big recoupment. The government, however, seems to be more willing to work with providers, and even reduce fees, for those who are making a good faith effort to comply with regulations and who have a working compliance program.
For companies without the proper compliance resources, I recommend working with a certified compliance professional to establish a program that aligns with the federal requirements, and then identifying internal team members who can oversee the program going forward. A compliance program can be set up with relatively low-cost, but needs to include all seven elements and needs to be properly overseen in order to be effective.
The costs associated with establishing a compliance program that matches the size of your ABA practice are essential to protecting your agency against unnecessary and unforeseen costs in the future.
Overall, regulatory compliance is a key focus area that every ABA company should have in place in order to protect their clients, contracts, and minimize costs. Although it may take some time, the companies who don't take compliance seriously and cut corners (whether they mean to or not), are hit the hardest with contract issues and revenue management, which ultimately leads to high stress and poor quality of care for clients. If you want more information on how to launch a compliance program or to meet with a certified compliance professional who specializes in ABA, please contact us at OutcomesBase.com.
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