Colorado’s fee-for-service Medicaid payments for applied behavior analysis did not fully comply with federal and state requirements, according to a February report from HHS’ Office of Inspector General.
The OIG audited 2022 and 2023 payments, examining whether the state’s fee-for-service Medicaid payments complied with federal and state requirements, and found that all 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper.
Among the sampled enrollee-months, 93 did not meet documentation requirements, 18 involved providers without appropriate credentials and seven lacked a diagnosis or treatment referral.
For potentially improper payments, 96 involved services not fully described, 88 reflected potential unallowable activities or care, 76 involved potential nontherapy time and 67 involved potential group activities.
The office estimated $77.8 million in improper payments, including a $42.6 million federal share, and $207.4 million in potential improper payments, including $112.5 million federal share, according to the report.
Colorado’s fee-for-service Medicaid payments for applied behavior analysis totaled $60.1 million in 2019 and increased to $163.5 million in 2023.
The Office of Inspector General made five recommendations: that Colorado refund $42.6 million to the federal government; provide additional guidance to applied behavior analysis facilities for documenting and billing; periodically conduct a statewide postpayment review of Medicaid applied behavior analysis payments to educate providers on requirements; review its prior authorization contractor’s procedures; and assess the $112.5 million federal share of potentially improper payments and refund any amounts found to be improper.
Colorado disagreed with one recommendation, agreed with three and partially agreed with one. The state also outlined steps it has taken and plans to take in response, the report said.
