Authored by Sylvia Xu via The Epoch Times (emphasis ours),
Colorado’s Medicaid program was found to have made approximately $77.8 million in improper payments and an additional $207.4 million in potentially improper payments for autism therapy, based on a report released in February by the Inspector General for the Department of Health and Human Services.
An audit was conducted on $289.5 million worth of Medicaid payments made between 2022 and 2023 for more than 1 million claims related to Applied Behavior Analysis—a therapy commonly used for treating autism and developmental disabilities.
Out of the 100 claims reviewed, each one was found to contain at least one improper or potentially improper payment, indicating a 100 percent failure rate.
It’s important to note that improper payments do not necessarily equate to fraudulent activities. Payments are deemed improper when they do not meet the federal or state requirements. Potentially improper payments are those where auditors are unable to verify the accuracy of the services provided due to inadequate or unreliable documentation.
Errors in Claims
In 93 out of the 100 claims reviewed, billing providers either failed to provide notes confirming the therapy sessions, did not include required signatures, or billed for more time than what was documented in the notes.
Additionally, in 18 instances, therapy that was supposed to be administered by a specialist, such as a Board Certified Behavior Analyst, was instead carried out by staff members lacking the necessary qualifications.
Furthermore, seven cases revealed that the children receiving therapy did not have a current doctor’s diagnosis or referral on file.
Other discrepancies included facilities billing for non-medical activities like academic tutoring, day care, or recreational activities. In one extreme case, a facility billed for children engaging in swimming and playing on water slides.
In 76 cases, facilities charged for a full eight-hour day without deducting time for breaks, meals, or naps.
Concerns about Oversight and Safety
The report highlighted that Colorado’s improper payments were a result of inadequate oversight. The state failed to conduct regular reviews of Medicaid payments to identify errors and did not provide clear guidelines to therapy centers on billing practices or what constitutes as legitimate therapy.
Furthermore, the state did not adequately monitor its prior authorization contractors to ensure compliance with regulations when approving therapy for children.
While the focus of the audit was primarily on financial discrepancies, it also uncovered issues that could compromise the safety and quality of care provided.
Some staff members were found to have criminal records for offenses such as weapons charges, assault, or driving under the influence. For instance, three staff members at a facility catering to an 11-year-old child with autism had previous criminal convictions.
One non-credentialed technician had a felony weapons offense conviction shortly before treating children, while another technician had prior convictions for misdemeanor assault and physical harassment. Yet another technician had an aggravated misdemeanor weapons conviction.
The state did not mandate background checks for these employees.
Prior Audit Findings
This report is part of a series of seven audits conducted by the Inspector General focusing on state Medicaid payments for autism therapy. While four audits have been completed, three are still ongoing.
Previous audits in states like Indiana, Wisconsin, and Maine estimated over $120 million in improper payments and nearly $200 million in potential improper payments.
Among these audits, the findings in Colorado revealed the highest potential for fraud, waste, and abuse in Medicaid payments for autism therapy.
The Office of Inspector General recommended that Colorado reimburse $42.6 million—the federal share of the improper payments—to the federal government.
Furthermore, the agency advised the state to implement regular reviews of autism facilities to ensure compliance with regulations and to provide better training and guidance to facilities on documentation and billing practices.
Colorado has agreed to enhance its guidance and increase the frequency of reviews moving forward, as stated in a release. However, it disagreed with the refund recommendation, citing that the audit’s findings were based on a limited sample and lacked sufficient details on the errors.
Moreover, Colorado argued that its Medicaid program does not necessitate certification of behavior technicians before making payments, thus suggesting that the refund calculation based on this requirement should be retracted.
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