Health Care

Citing Medicaid fraud, state freezes enrollment of autism therapists in South Florida

In this November 2013 photograph, Sophie Cordoba teaches a 13-year-old boy in the Applied Behavioral Analysis classroom in Miami.  This week, Florida healthcare regulators imposed a six-month moratorium on enrollment of new behavior analysis providers into the Medicaid program, citing massive fraud and abuse.
In this November 2013 photograph, Sophie Cordoba teaches a 13-year-old boy in the Applied Behavioral Analysis classroom in Miami. This week, Florida healthcare regulators imposed a six-month moratorium on enrollment of new behavior analysis providers into the Medicaid program, citing massive fraud and abuse. The Miami Herald

Florida healthcare regulators are imposing a six-month moratorium on enrollment of new therapists who provide a costly but effective psychological treatment for poor children with autism in Miami-Dade and Broward counties, citing a statewide investigation that identified fraud and abuse, including "extraordinary overbilling," of the Medicaid program.

But while the state's Agency for Health Care Administration, or AHCA, said on Monday that no Medicaid recipients will go without the services they deserve during the moratorium, Florida psychologists and other providers of the autism therapy, called behavior analysis, said their most vulnerable patients have been going without needed treatment for months because the state stopped authorizing services in March.

Even before the moratorium, though, some behavior analysis providers said they were having trouble getting paid.

Shelly Lynn Henry, a behavior analysis provider with Trinity ABA in Pasco County, launched an online petition calling on Gov. Rick Scott to authorize the psychological services that psychologists and others provide to low-income children with special needs, developmental disabilities, depression and other disorders.

AHCA officials said the petition's allegation that the state had stopped authorizing behavior analysis services in March was false.

Statewide since March, according to Mallory McManus, an AHCA spokeswoman, the agency has enrolled 190 new behavior analysis providers and authorized 10,542 Medicaid recipients to receive behavior analysis services.

McManus added that AHCA has not received any requests from Medicaid patients for a grievance hearing over behavior analysis services that have been stopped or denied.

Behavior analysis, which is designed to improve the behavior, language and cognitive development of autistic children, is an evidence-based treatment for autism endorsed by the federal Centers for Medicare and Medicaid Services, the U.S. Surgeon General, the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the health departments of several other states.

Autism, typically diagnosed around age 2, is one of the most common developmental disabilities, afflicting about one in every 59 children, according to the CDC. A neurological disorder, autism often affects a child's ability to speak, learn and interact with others.

The online petition, signed by almost 10,000 people, notes that AHCA had stopped authorizing behavior analysis services on March 1, citing "technical difficulties."

When initial reports surfaced about the state delaying authorization for behavior analysis services, Shelisha Coleman, an AHCA spokeswoman, issued a written statement May 8 urging Medicaid patients to contact the agency if they were not receiving necessary services.

One week later, AHCA officials explained the reason for the delays — alleged mass fraud by behavior analysis providers.

In announcing the moratorium, AHCA, which administers Florida's Medicaid program in partnership with federal officials, said the freeze will "prevent significant fraud that impacts taxpayers and potentially compromises the quality of care patients receive."

A 15-page application to the federal government requesting authorization for the moratorium spelled out some of the Florida healthcare agency's investigative findings. The agency noted that it has been investigating more than 100 group providers and more than 700 individual providers who allegedly enrolled through deceptive and improper practices.

It's unclear whether AHCA's investigation focused specifically on Miami-Dade and Broward, but the agency's application for the moratorium noted that the investigations began as pilot projects to test a "risk-assessment tool" that identified Miami-Dade as a "high risk area."

Additional reviews of data suggested that Broward and some Central Florida regions should also be considered for closer scrutiny, the application states.

Among the investigative findings cited by AHCA:

Providers attempting to bill "unbelievable hours" — more than 24 hours per day, more than 40 hours per week, and billing in excess of 31 days in a row.

Some providers may have falsified their qualifications, exposing patients to behavioral analysis services from unqualified providers.

Miami-Dade currently has 8,175 behavior analysis providers enrolled in the Medicaid program, and 5,676 recipients receiving those services, a ratio that AHCA called "abnormally high."

More than a dozen large provider groups have been referred to the Office of the Attorney General’s Medicaid Fraud Control Unit for investigation of suspected criminal activity.

AHCA officials said investigations are continuing and are expected to lead to additional referrals to the Florida Attorney General's Medicaid fraud unit, and sanctions against current providers.

Monday's moratorium on enrollment of new behavior analysis providers for Florida's Medicaid program is the latest chapter in a long-running feud between AHCA and parents of children with autism who have sued the agency in federal court seeking the services.

In March 2012, U.S. District Judge Joan Lenard signed an order requiring AHCA to begin paying for behavior analysis. AHCA then appealed the order, and, in a pleading submitted in November 2012, argued that the ruling stripped the state of its ability to weigh requests for the therapy on a case-by-case basis to ensure the treatments are "medically necessary."

The appeal was granted in part to clarify that the judge's order did not strip the state of its authority to make individual medical necessity determinations.

Miami Herald Staff Writer Carol Marbin Miller contributed to this report.

A previous version of this story stated that the Agency for Health Care Administration's appeal failed. The agency's appeal was granted in part and denied in part.