Health Care

Florida autism therapists say Medicaid payment delays harm patients and hurt business

Kat Diaz, right, a registered behavior technician with the Broward Children's Center, a nonprofit in Pompano Beach, provides behavioral analysis, a therapy that helps children with autism learn to lead more independent lives. A state freeze on Medicaid-funded providers in South Florida, and months-long delays in authorizations for services, have hampered the program, administrators said.
Kat Diaz, right, a registered behavior technician with the Broward Children's Center, a nonprofit in Pompano Beach, provides behavioral analysis, a therapy that helps children with autism learn to lead more independent lives. A state freeze on Medicaid-funded providers in South Florida, and months-long delays in authorizations for services, have hampered the program, administrators said. Courtesy Broward Children's Center

Jennifer Borr built a private practice in South Miami eight years ago to help children with autism and other developmental disabilities learn to lead more independent lives — a vocation she says is now threatened by the state's recent moratorium for Medicaid-funded therapists in South Florida and by months-long delays in approvals for the therapeutic technique she provides called Applied Behavioral Analysis.

Borr and her staff at Shine Bright Therapy were already enrolled as state providers for Medicaid patients when the state's Agency for Health Care Administration or AHCA announced the moratorium for Miami-Dade and Broward counties, citing rampant fraud.

The trouble, she said, is that AHCA, the state agency that manages Medicaid in Florida, has not authorized services for her clients since about February — forcing Borr to pay staff out of her own pocket. Her cash flow has slowed to a trickle as she waits for approvals.

"This is huge. This could close my doors," said Borr, whose practice employs eight therapists and provides care to about two dozen children, most of them recipients of Medicaid, the public health insurance program for disabled and low-income Americans.

When AHCA announced the moratorium, the agency said all existing providers could continue to deliver and bill for authorized services, emphasizing that, "No Medicaid recipients will go without the services they deserve." The agency encouraged patients to call the agency at 877-254-1055 if they have difficulty finding therapy.

"AHCA's focus is on ensuring the persons who need these services are getting them from a qualified person," AHCA spokeswoman Mallory McManus said Wednesday. She added that the agency has enrolled 218 behavioral analysis providers statewide in the Medicaid program between March 1 and May 29.

But Borr and other behavioral analysis providers in Florida say their patients, mostly children with autism, are going days and weeks without needed therapy because authorizations from the state have been halted. They say their patients are losing the progress they've made. In behavioral analysis, certified therapists analyze a patient's adverse behaviors and develop individualized treatment plans so the patients can learn and change the way they act, from controlling aggression to speaking and writing.

"With autism kids, that time off can really affect them," Borr said. "We’re doing intensive therapy, so one week can make a big difference, depending on the child."

Lori Sugar, a certified behavioral analyst with Broward Children’s Center, a nonprofit group in Pompano Beach, said her organization also has been forced to turn away families with Medicaid whose children need therapy. The reason: delays in authorization for services, and cuts in the amount of therapy approved for patients.

"Everything came to a screeching halt," said Sugar, who was hired about 18 months ago to launch and oversee a behavioral analysis program for the center. "It’s seriously impacting our ability to provide services for children."

Sugar said the work is labor intensive, requiring behavioral analysis technicians, assistants and supervisors to work with children from 10 to 30 hours a week. Because there have also been delays enrolling new behavioral analysis technicians, assistants and supervisors for Florida's Medicaid program — even prior to the May 14 moratorium for Miami-Dade and Broward — Sugar said she has also been unable to hire enough workers to grow the program.

"It’s taking months for them to process the applications," Sugar said Wednesday. "So now I have a waiting list. ... I don’t have a staff of behavior technicians to process services for people who are calling in need of services. I talked to two Medicaid families today. I told them, 'You guys need to call AHCA'."

Because Sugar works for a private nonprofit, the group can survive financially even with delays and cuts in Medicaid's behavioral analysis services. But smaller providers, such as Borr, said they have been paying their staff out of their own pockets while waiting for authorization to continue providing services to existing clients and approvals for new clients.

"I’ve been financially struggling for months now," Borr said. "I shouldn’t have to be worried about paying my therapists. They’re doing a good job."

The delays began in February when AHCA hired a private company to review all requests for behavioral analysis services provided to Medicaid patients, according to three therapists who spoke with the Herald. Prior authorization is required for therapists to get paid for their services, and Borr and other providers say it's impossible for them to plan for the future and take on new clients without knowing whether the services will be authorized or for how long.

The company AHCA hired, a private firm called eQHealth Solutions, has taken longer to authorize requests than the prior company, the providers said. And when therapists do receive approval for services from eQHealth, they say it's often for about half the amount of therapy they used to provide and the documentation required to justify those services is much more intensive.

Shelly Lynn Henry, who owns a practice called Trinity-ABA in Hernando County, said she's facing the possibility of closing temporarily or selling her business because of the delays in authorization for services to her clients, who are mostly autistic children with Medicaid. She said Wednesday was the last day her clients were authorized to receive therapy.

"If we don’t have those authorizations in hand, we can’t provide those services tomorrow," Henry said on Wednesday. "Staff knows the situation and it’s beyond our control. I believe we will be authorized and it will just be delayed."

Many children with autism and other developmental disabilities need 30 to 40 hours a week of behavioral analysis therapy, Henry said. She estimates that the cost to Medicaid for six months of behavioral analysis therapy, including technicians, assistants and analysts, can range from $40,000 to $60,000 per patient.

And because Medicaid provides behavioral analysis services to patients with many types of disorders, including attention deficit and hyperactivity disorder, post traumatic stress disorder and Down syndrome, the demand for therapy has spiked, Henry said.

McManus, the AHCA spokeswoman, said that eQHealth has authorized more than 12,000 Medicaid recipients to receive behavioral analysis services between March 1 and May 29.

Like Borr, Henry said she has been paying her five therapists with her own money, expecting to be reimbursed for services for about a dozen clients. But delays and changes in authorization for services have hobbled her practice, she said.

"It’s not that we couldn’t get any services authorized, it’s that they only authorize 50 percent of what we would normally be able to get and they would only authorize for weeks at a time," said Henry, who launched an online petition asking Gov. Rick Scott to intervene.

Henry said eQHealth has also asked for extra documentation to justify behavioral analysis services for patients, including a comprehensive diagnostic report prepared by a licensed physician outlining the adverse behavior to be addressed.

Borr, the therapist in South Miami, said she has called eQHealth to complain, but that no one can tell her when she's going to get paid. Instead, she said, they keep asking for more documentation.

"They’ll give us a response and say, 'Now we need this, this and this'," she said. "Then two, three or four days go by and you’re hoping they’re going to push this authorization through and then they’re requesting more documentation. You’re wondering, 'Is this a delay tactic?'."

For families of children with developmental disabilities and who rely on behavioral analysis, the delays are causing them to lose progress on milestones that had dramatically changed lives.

Lisa Calby, 59, cares for a 10-year-old grandson with autism who receives behavioral analysis therapy with Henry at Trinity-ABA. Calby, who agreed to speak with the Herald on condition that her grandson be identified by his initials, L.C., said the boy has received fewer hours of behavioral analysis for months, and that he has regressed without consistent therapy.

L.C. had been receiving almost daily sessions of behavioral analysis, she said, and the improvement in his social and learning skills were dramatic.

"When I first got him," Calby said, "he was humming a lot. He wasn’t talking, but he was humming. He wouldn’t get dressed. He wouldn’t brush his teeth. It was impossible to take him out to church. He couldn’t be around a lot of people."

But after four years of behavioral analysis therapy, Calby said, she can now take her grandson to the dentist without him being overcome with anxiety. She can also trim his hair in one sitting, instead of bit by bit over several days, which always left L.C. with an uneven cut.

"He sits at church with me now," Calby said, "where before I couldn’t get him to go into church at all. He is hanging on me a lot, because of the people. But he can sit through the music, and before he needed to have headphones."

Calby said L.C.'s behavioral therapy has been reduced from about 40 hours a week to 20 hours or less weekly.

"When these services started getting cut," she said, "what we saw was definitely an increase in behavior. We saw him being less engaged in things. He would just sit in a chair a lot by himself. He was less engaged."

Calby said she understands that AHCA must do something to stop Medicaid fraud. But she wishes the agency would help legitimate providers keep practicing.

"If there’s fraud in Medicaid," she said, "you don’t stop everything. Children need this service because these services keep them safe."

Daniel Chang: 305-376-2012, @dchangmiami