??The Hidden Risks in ABA Billing: Why Accurate Documentation Matters

The healthcare industry is facing unprecedented scrutiny, and ABA services are no exception. With increasing audits, regulatory oversight, and fraud investigations, now more than ever, providers must ensure their documentation is clear, accurate, and compliant. The reality is that improper documentation and billing practices in ABA services can have far-reaching consequences—not just for providers, but for the patients who desperately need these services.

Are Providers Padding ABA Claims?

A growing concern in ABA billing is the inclusion of non-billable activities, whether intentional or not. Some providers have been adding activities like nap times, snack times, mealtimes, or even casual walks around the neighborhood to their billable hours. While these activities may be part of a client's daily routine, they are not ABA services unless there is clear documentation supporting a therapeutic interaction.

For example, if a therapist arrives at a client’s home and the child is eating a meal, that time should not be counted as billable service time unless a documented intervention is occurring. Even more concerning is the inclusion of nap times—an absolute red flag. You simply cannot provide ABA therapy to a sleeping child.

Additionally, when the place of service changes, time should stop, and a new note must be created. Failing to do so raises compliance issues that could lead to investigations.

Red Flags SIUs and Payers Should Watch For

Special Investigation Units (SIUs) and payers are cracking down on improper billing practices in ABA services. Some of the biggest red flags include:

• Impossible workdays – Billing for more hours than physically possible in a day.
• Overbilling units – Reporting excessive service time beyond what is reasonable.
• Supervision fraud – Billing for supervision services where staff are supervising themselves. Supervision is meant for a Board-Certified Behavior Analyst (BCBA) to instruct an ABA Technician on treatment plan updates, not for simply observing their work.
• Incomplete documentation – Adding a progress grid to a medical record does not justify billing for an ABA service. The note must be clear, concise, accurate, and complete.

When documenting, providers should ask themselves:

• Would an outside auditor understand what service was provided, the outcome, and the next steps?
• Would a judge comprehend the documentation if it were presented in court?
• Would a patient’s parent clearly understand what was done and why?
• Are abbreviations and acronyms universally recognized?

The Ripple Effect of Poor Documentation

The stakes are high. When ABA documentation is inaccurate or inflated, everyone loses:

• Providers face penalties, audits, and legal action. Agencies engaging in improper billing may be subject to hefty fines and possible exclusion from payer networks.
• Patients experience delays or denials in care. Payers scrutinizing excessive billing may delay or withhold services, directly impacting the children who need ABA therapy the most.
• Payers may tighten coverage policies. If fraud and abuse persist, payers may revise their reimbursement policies, limiting access to necessary services for all ABA patients.

How to Tighten Oversight and Prevent Issues

The key to preventing these issues is education and proactive compliance. Providers must:

• Stay informed of state and federal regulations. Ignorance of billing updates is not a defense.
• Work with certified coders. Coders ensure documentation aligns with the latest guidelines.
• Use the correct code sets. Some providers are still billing outdated codes that were retired in 2019. Staying up to date is essential to compliance.

A simple rule of thumb: If you have to explain your note after completing it, it isn’t clear enough. Before finalizing documentation, have a second set of eyes review it. Be open to feedback and give constructive feedback to colleagues when needed.

With heightened regulatory scrutiny in healthcare, ABA providers must step up their compliance efforts. Proper documentation is not just about reimbursement—it’s about maintaining integrity in the healthcare system and ensuring that patients receive the care they deserve.

By Robyn Marie Alvarado, CPC, CPMA | Documentation Auditor Advize