tricare operations manual changes and your aba …
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TRICARE OPERATIONS
MANUAL CHANGES
AND YOUR ABA ORGANIZATIONJune 15, 2021
Ellen Bonner, Esq.
Attorney
Callaway Bonner Law, LLC
Meet Today’s Presenter!
Anna Bullard
VP Government Relations
BHCOE
6/15/216
Changes to the TRICARE Operations Manual (TOM)Autism Care Demonstration (Chapter 18, Section 4)
March 23, 2021
Background
● DHA Autism Demonstration Program began 2014 and ends December 31, 2023.
● Defense Health Agency’s 2020 Annual Congressional Report to Congress – June 25, 2020).
○ Revisions intend to reduce potential fraud, waste and abuse via more comprehensive
oversight prior to treatment plan authorization as well as improved post claims payment
audits.
○ ABA treatment outcomes do not correlate to treatment intensity, and the overall results
show limited clinical improvement, support a needed change to the Autism Care
Demonstration.
6/15/218
History of ABA Services Under TRICARE
“Medically Ready Force…Ready Medical Force”TRICARE Autism Care Demonstration And The Way Ahead (Defense Health Agency Presentation - April 11, 2019) 6/15/219
TOM – A Few of the Changes
● New Participations Agreements executed prior to August 1, 2021.
● All ABA care must be “Authorized” in advance.
○ No payment for care provided before authorization.
● Retroactive referrals for ABA services will not be accepted. (TOM Chapter 18,
Section 4, Paragraph 8.6.1.)
● Completed Treatment Plan – including Outcome measures – must be submitted
prior to issuing the next six-month treatment authorization.
● Authorizations issued prior to August 1, 2021, and their associated claims remain
active until the next authorization period. Revisions to the existing authorizations
are not permitted. (8.6.2.3)
● 15 exclusions listed at paragraph (8.10)
● Progress Note Documentation (8.7.2)6/15/2110
TOM – A Few of the Changes Continued
● Autism Services Navigator (“ASN”) – a new layer of “care management”.
○ BCBAs and assistant behavior analysts cannot be an ASN.
○ If new beneficiary/family decline ASN, no longer eligible for Autism Care
Demonstration (6.8)
● ABA Provider Steerage Model – Implemented by January 1, 2022
● Contractor shall assign beneficiaries to ABA providers who rank highest in the
steerage model when possible, consistent with access to care standards.
(9.3.12)
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Reauthorizations – ABA Providers At Risk
● Reauthorizations – must be submitted no later than 30 calendar days in advance. (May be submitted up to
60 days in advance.) (8.6.3.1)
● Termination of ABA services under any circumstances must not occur abruptly by the authorized ABA
supervisor. All termination plans must be at least 45 calendar days prior to the termination of services.
(8.8.2)
● The contractor shall, should ABA services be terminated abruptly by the authorized ABA supervisor, report
the authorized ABA supervisor to the appropriate credentialing/licensure board. 8.8.2.2
● If, the ABA supervisor – aka the BCBA, BCBA-D, or Clinical Psychologist - fails to seek an authorization
timely (within 30 days of the date services are no longer authorized), the ABA provider is at risk for non-
reimbursable ABA services until the new authorization is issued if the existing authorization expires
prior to the approval of the next authorization. (8.6.3.1)
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Reauthorizations – ABA Providers At Risk Continued
The DHA attempts to compel ABA Providers to provide ABA services free of
charge if the provider does not seek a new authorization timely and a termination
plan is not in place.
This TOM provision places the ABA provider in a double-bind – forcing the ABA
provider to provide ABA services to the Federal Government and its TRICARE
beneficiaries without compensation. Should the ABA services not be provided, the
TRICARE Managed Care Support contractors shall submit notice of disciplinary
action to the ABA provider’s certifying/licensing body. (8.8.2.2 and 9.3.5).
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Reauthorizations – ABA Providers At Risk Continued
The DHA failed to consider:
● The Antideficiency Act, 31 USC 1342 which prohibits federal agencies from
accepting voluntary services.
● The Government cannot delegate to a contractor an inherently governmental
function. Federal Activities Inventory Reform (FAIR) Act of 1998. A government
contractor cannot adjudicate a “notice of disciplinary action” and report this action
to the ABA provider’s certifying and licensing body.
○ There is no Due Process for the ABA provider.
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Audits – Administrative Claims Review – Annual Review
● Annual Audits – A minimum of 30 records audited annually for each Autism Corporate Services
Provider or Sole Provider (8.9.2)
● Administrative Claims Review (8.9.7.2) – Contractor shall target detection and prevention efforts
of services that pose the greatest risk of fraud and abuse to the TRICARE program. These
include reviews of TRICARE providers with:
○ High-dollar billing patterns
○ Changes in billing frequency
○ Claims patterns of “impossible days” (provider’s total claims exceed 12 hours per any given
calendar day).
● Annual Reviews (8.9.10) – Contractor to conduct an annual audit of a statistically valid number of
providers to ensure providers meet the ABA Provider Requirements (8.2 and 8.4).
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Education
● Provider Education – Providers must attend a contractor-hosted “provider
education” training no less than annually beginning no later than October 1,
2021. (8.3.10)
○ 10% claims penalty for all rendered services when an ABA provider is non-
compliant with the annual contractor training after October 1, 2021 (8.3.10)
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Education Continued
• Contractor is required to develop the provider education training, to be implemented no later than January 1, 2022 (9.3.3).
Includes:
o Autism Care Demonstration requirements
§ ABA provider requirements
§ Correct billing practices/claims filing
§ Authorizations
§ Exclusions
§ Medical records documentation
§ Provider responsibilities
§ Program requirements
§ Basic TRICARE rules
§ 32 CFR 199
• Contractor shall educate and monitor providers with identified insufficiencies in clinical documentation for a minimum of six
months, but not later than 12 months. (8.9.8.3)
o ABA providers who have not improved after a minimum of six months, but no later than 12 months of education and
monitoring shall be placed on pre-payment review. (8.9.8.5)
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Tools for TRICARE ABA Providers
ü Internal audits of medical records to ensure compliance.
ü TRICARE training of staff to emphasize compliance.
○ Ensure that staff are signing medical records legibly.
ü Consider seeking an injunction to stop any changes or enforcement until
TRICARE corrects all problems with the TOM.
6/15/2118
Q&A
THANK YOU