LINCOLN — Nebraska officials for months have anticipated the federal government possibly stepping in to review soaring state expenses for autism-related services for youths, as has been the case elsewhere across the country.

This week, Nebraska State Auditor Mike Foley beat them to the punch.

On Tuesday, Foley released his team’s examination of state costs to deliver Applied Behavioral Analysis services to Nebraskans. That’s a widely used therapeutic approach that helps youths with autism spectrum disorder and other developmental and social communication delays function better in society.

The auditor’s 24-page report noted deficiencies such as a few duplicate claims for ABA services submitted by certain companies, resulting in what the auditor described as needless costs being paid by the Nebraska Department of Health and Human Services.

Foley said in a statement that the audit sample was “quite limited” and that more instances likely would surface with broader reach. He said the report offers DHHS insight and another “roadmap on how to mitigate” such problems.

“DHHS has a full plate in front of it as it addresses the rapidly expanding population of citizens needing ABA services while trying to control the budgetary impact of service delivery,” Foley said.

Review was welcomed

The review was requested by DHHS CEO Steve Corsi, Foley said. Its findings come as DHHS has implemented changes to the ABA program — sparking controversy and challenges from families and advocates for youths with autism.

In August, DHHS reduced Medicaid reimbursement rates to providers of the services. Months earlier, it created and approved new guardrails aimed at more efficiency and accountability.

The attention came in light of ballooning state costs to provide ABA services. DHHS has said that before the August changes, Nebraska had the highest reimbursement rates of any state for the therapy. The agency said those higher rates contributed to the increase in state expenses from $4.6 million in 2000 to about $85.6 million last year.

State auditors said the number of companies working with DHHS through Heritage Health to deliver autism services to low-income and eligible young Nebraskans has nearly quadrupled in five years from 10 to 38.

DHHS Medicaid officials have said the agency’s recent efforts were intended to set clearer parameters, expectations and to rein in potential overauthorization of services. They said they’re cognizant and have monitored federal audits and multimillion-dollar fines levied against other states’ Medicaid-covered behavioral health programs, and want to minimize the risk to the state of federal efforts to claw back funds. 

Earlier this month, Nebraska lawmakers held a public hearing to hear how the recent state cuts to Medicaid reimbursement for ABA services had affected Nebraska and its youngest members on the autism spectrum. The hearing was part of an interim study to inform the Legislature how it might help ensure the viability of Medicaid-funded ABA services.

Foley said his team’s audit did not play a role in DHHS’ decision to revise reimbursement rates. He believes the rates were the driving reason for fast-rising costs and said the auditor’s review could provide insight into internal deficiencies that could lead to better efficiencies.

The audit, Foley said, revealed examples of costly, “erroneous” claims for reimbursement filed with the managed care organizations that process claims for the state’s Medicaid program and a need for better support documentation. 

Among deficiencies noted by state auditors:

 

  • Two claims that appeared to be duplicate payments of claims previously paid led to potential overpayment of about $29,500.
  • A “significant number of claims” lacked adequate information on service providers. “Testing revealed, moreover, that the service provider designated in the claim data did not agree to the actual service provider for 87 of the 179 claims tested,” the report said.
  • Several providers “lacked professional credentials to be a service provider yet successfully billed DHHS for services,” Foley said. The audit report said lax qualification checks increase risk for children not receiving appropriate care. 
  • Limited testing showed one claim paid at a rate more than three times the approved Medicaid reimbursement rate, resulting in overpayment of $603. The provider agreed to repay the amount, the auditors noted.

 

The audit recommended continued review and update of service definitions for the ABA program and more specific guidance on documenting claims.

DHHS, in an overall response included in the audit report, said the agency appreciated the review that it asked for: “This collaborative effort provides the department with an objective review of the ABA program, which will be used to make program improvements.”