Evidence record
Wisconsin’s Fee-for-Service Medicaid Payments for Applied Behavior Analysis
- Jurisdiction
- Wisconsin
- Publication date
- July 2025
- Source record
- Original document linked
Findings
12
Recommendations
6
Overall 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.
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).
Findings (12)
Each finding has a stable link.
- F-317
Estimated improper payments totaling at least $18.5 million ($12,287,252 Federal share).
- F-318
Estimated potentially improper ABA payments totaling approximately $94.3 million ($62,334,835 Federal share).
- F-316
All 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper.
- F-319
Session notes did not support CPT codes billed (79 enrollee-months).
- F-320
Session notes did not support the number of units billed (77 enrollee-months).
- F-321
Session notes did not support the dates of service billed (16 enrollee-months).
- F-322
Session notes did not include signatures of rendering providers (9 enrollee-months).
- F-323
The State agency did not perform a statewide postpayment review of ABA payments since 2016 and did not provide sufficient guidance to ABA providers.
- F-324
Some session notes referred to recreational activities or included potential nontherapy time, and some notes misidentified rendering providers.
- F-325
Cloned or unreliable session notes identified across multiple enrollee-months; notes often identical or reused.
- F-326
Incorrect rendering provider identified on claims for a number of enrollee-months (e.g., 97153 vs 97155 under different providers).
- F-327
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)
- R-289
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.
Related finding F-319 - R-290
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.
Related finding F-323 - R-291
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.
Related finding F-327 - R-292
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.
Related finding F-323 - R-287
Refund $12,287,252 (Federal share) to the Federal Government for FFS Medicaid ABA payments that did not comply with Federal and State requirements.
Related finding F-317 - R-288
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.
Related finding F-318