Colorado Made at Least $77.8 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children
Learn how the AI-generated research projects were createdOverall Conclusion
Colorado’s FFS Medicaid payments for Applied Behavior Analysis provided to children did not fully comply with Federal and State requirements, resulting in improper and potentially improper payments and highlighting a need for stronger governance, oversight, and guidance to prevent future noncompliance.
Source Document
Audit Scope
Audit covered Colorado's Health First Colorado, the State's Medicaid program, focusing on fee-for-service Medicaid payments for Applied Behavior Analysis (ABA) for calendar years 2022 and 2023. The audit analyzed $289.5 million ($158.2 million Federal share) across 1,057,164 claim lines and 60,131 enrollee-months, with service dates from January 1, 2022 through December 31, 2023 for enrollee-months with payments over $1,000.
Key Findings Summary
All 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper.
Session notes or EVV records did not meet documentation requirements.
ABA was provided by staff who did not have the appropriate credentials.
View the Findings tab to see all 7 findings
AI-Assisted
AI-Generated Insight
The audit identifies systemic gaps in documentation, credentialing, and oversight of prior authorizations for ABA services in Colorado. Without statewide postpayment reviews, robust EVV and signature controls, and clear provider guidance, improper payments are likely to recur. The report’s recommendations aim to implement governance and educational measures to reduce risk in future audits.
Audit Objectives
Determine whether the State agency’s FFS Medicaid payments for ABA provided to children complied with Federal and State requirements.
Audit Findings (7)
All 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper.
Session notes or EVV records did not meet documentation requirements.
ABA was provided by staff who did not have the appropriate credentials.
ABA was provided to children without documentation of a comprehensive diagnostic evaluation or treatment referral for ABA.
The State agency did not perform a statewide postpayment review of ABA payments and did not provide sufficient guidance to ABA facilities.
Oversight of the prior authorization contractor was insufficient to ensure compliance with diagnostic evaluation and referral requirements.
The audit estimated improper payments totaling at least $77.8 million ($42.6 million Federal share) and potentially improper payments totaling $207.4 million ($112.5 million Federal share).
Recommendations (5)
Refund $42.6 million to the Federal Government.
Provide additional guidance to ABA facilities for documenting and billing ABA.
Periodically perform a statewide postpayment review of Medicaid ABA payments to educate providers on requirements.
Strengthen oversight of the prior authorization contractor to ensure that prior authorizations are approved with documentation of required diagnostic evaluations and treatment referrals.
Provide guidance on documentation, credentialing, EVV, and signature requirements; ensure facilities bill only for allowable ABA activities.