Wisconsin’s Fee-for-Service Medicaid Payments for Applied Behavior Analysis
Learn how the AI-generated research projects were createdOverall Conclusion
The Wisconsin Department of Health Services’ ForwardHealth program did not provide adequate oversight of FFS Medicaid ABA payments, resulting in improper and potentially improper payments for autism-related ABA services. The program had not conducted a statewide postpayment review since 2016, and supporting documentation deficiencies were prevalent across sampled enrollee-months, with estimated improper payments of at least $18.5 million and potentially improper payments totaling about $94.3 million. The findings indicate significant gaps in documentation, coding, and provider guidance, which could affect the quality of care for children with autism and the program’s financial integrity.
Source Document
Audit Scope
Audit covered the State agency’s total FFS Medicaid payments for ABA to enrollees 21 years and younger for the period January 1, 2021, through December 31, 2022, within Wisconsin’s ForwardHealth program. It analyzed 1,110,716 claim lines totaling $121.1 million ($80.8 million Federal share) across 36,345 enrollee-months. A stratified random sample of 100 enrollee-months (payments totaling $389,997; Federal share $258,035) was reviewed, encompassing 22 unique ABA facilities and 98 unique enrollees. The audit evaluated prior authorizations, diagnostic evaluations, prescriptions, plans of care, and session notes to determine compliance with Federal and State requirements, focusing on CPT codes (97151, 97153, 97155, 97156, 97156AM), session-note content and signatures, and provider rendering information. The audit did not assess medical necessity but sought to determine compliance with documentation and coding requirements and the adequacy of the State agency’s oversight (including postpayment reviews).
Key Findings Summary
Estimated improper payments totaling at least $18.5 million ($12,287,252 Federal share).
Estimated potentially improper ABA payments totaling approximately $94.3 million ($62,334,835 Federal share).
All 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper.
View the Findings tab to see all 12 findings
AI-Assisted
AI Scope Summary
Assess whether Wisconsin’s FFS Medicaid payments for ABA to children with autism, during 2021–2022, complied with Federal and State requirements, focusing on documentation quality, CPT-code billing accuracy, rendering-provider accountability, and the sufficiency of statewide postpayment review.
AI-Generated Insight
This audit reveals systemic gaps in Wisconsin’s oversight of ABA billing and documentation, highlighting a substantial financial risk ($112.8M across improper and potentially improper payments) and potential implications for patient care. It underscores the need for robust postpayment reviews, precise CPT-code guidance, and clear documentation standards to ensure both fiscal accountability and effective treatment for autistic children.
Audit Objectives
Determine whether the State agency’s FFS Medicaid payments for ABA provided to children diagnosed with autism complied with Federal and State requirements.
Audit Findings (12)
Estimated improper payments totaling at least $18.5 million ($12,287,252 Federal share).
Estimated potentially improper ABA payments totaling approximately $94.3 million ($62,334,835 Federal share).
All 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper.
Session notes did not support CPT codes billed (79 enrollee-months).
Session notes did not support the number of units billed (77 enrollee-months).
Session notes did not support the dates of service billed (16 enrollee-months).
Session notes did not include signatures of rendering providers (9 enrollee-months).
The State agency did not perform a statewide postpayment review of ABA payments since 2016 and did not provide sufficient guidance to ABA providers.
Some session notes referred to recreational activities or included potential nontherapy time, and some notes misidentified rendering providers.
Cloned or unreliable session notes identified across multiple enrollee-months; notes often identical or reused.
Incorrect rendering provider identified on claims for a number of enrollee-months (e.g., 97153 vs 97155 under different providers).
There was no formal procedure to verify the rendering provider for 97153-focused treatments to ensure payment aligned with the rendering provider’s specialty level.
Recommendations (6)
Update guidance for CPT code 97155 to require documentation on how issues were resolved or what changes were made to the treatment protocol or POC.
Provide additional guidance to ABA facilities about how to document ABA, including the information needed in session notes to support ABA provided and billable ABA time, and State signature requirements.
Develop a procedure to verify the provider who rendered the 97153-focused treatment service and pay the claim based on the rendering provider’s specialty level.
Periodically conduct a statewide postpayment review of Medicaid ABA payments, including reviewing session notes, and provide training in areas where errors were identified by postpayment reviews.
Refund $12,287,252 (Federal share) to the Federal Government for FFS Medicaid ABA payments that did not comply with Federal and State requirements.
Review and determine whether the estimated $62,334,835 (Federal share) in potentially improper ABA payments complied with Federal and State requirements and refund the Federal share of any improper payment.