Therapists who work with autistic children in the Medicaid system are having problems getting required state credentials, according to providers.
The issue has been going on for months and is impacting how many patients clinics can serve, the providers said.
About 41,000 children statewide receive applied behavior analysis therapy, commonly called ABA therapy, through the Florida Medicaid system. The state says while recipients are not required to have a specific diagnosis, they must exhibit maladaptive behaviors – like screaming, biting and head banging.
More than 90 percent of those who receive this therapy are diagnosed with Autism Spectrum Disorder.
The issue
The state spent the past two years cracking down on fraudulent billing practices by clinics that provide behavior analysis therapy to children on the autism spectrum.
But now, behavior analysis agencies say the state is making provider credentialing difficult, and in some cases, is retracting the credentials for a position called a registered behavior tech, even if the agency previously approved their paperwork.
Some providers say this means their clinics are no longer able to serve some children because these techs are the backbone of their practice.
"Without your RBTs you don't have an agency,” said Angie Smith, the owner of Amazing Gains Behavior Therapy Services in Orlando.
The state Agency for Health Care Administration lists three types of providers that can deliver behavior analysis services: Behavior Analyst Certification Board, Certified Lead Analysts - Board Certified Assistant Behavior Analysts and Registered Behavior Technicians (RBT).
RBTs are providers who possess at minimum a high school diploma and have undergone 40 hours of training and passed an exam. RBTs are the most numerous provider type and can deliver services under the supervision of a Lead Analyst.
So when clinics struggle to get these RBTs credentialed, it impacts how many children they can serve. And if the state decides to suspend them to ferret out fraud, they’re not able to service their current clients either.
Angie Smith said on Dec. 1, the Agency for Health Care Administration emailed providers telling them they had four weeks to provide the paperwork proving all their techs are credentialed.
"So within two weeks we had compiled, everything put it in order, had it submitted well before the deadline on Dec. 21,” Smith said. "Medicaid made the decision to suspend 100 percent of our technicians anyway."
Smith's not alone. Numerous clinics on a private Facebook forum for ABA providers complained about the same thing. Many of them have sent complaints to the office of Sen. Debbie Mayfield, a Rockledge Republican who serves on the Senate Health Policy Committee.
Beth Kidder, a deputy secretary of the state Agency for Health Care Administration, told members of the Senate Health Policy Committee in early January that the state had frozen payments to behavioral analysis providers until they could verify that they met new certification requirements that went into effect Jan. 1.
But clinics were told to continue services for children despite not being reimbursed while the paperwork was approved. Angie Smith said that’s just not realistic. She said agencies were encouraged by the state to “take out loans” to pay their staff in the meantime.
“For for most agencies it's not an option for us to do that, like four weeks without any reimbursement whatsoever,” Smith said. “When you have 20 staff you can only float that for so long before you have no choice and these kids are going to lose their services until we can receive reimbursement – it’s just that simple.”
How it impacts the children
The Agency for Health Care Administration has repeatedly said in the past year that no child has lost services due to last summer’s authorization snags or the current credentialing issues. But some, like Florida Association for Behavior Analysis founder Jon Bailey, disagree.
“No, that's not the least bit true,” Bailey said.
Bailey said his organization put a call out to their members about denials and the names came flooding in. He says those names were given to the state.
"They cherry picked on those names and put them to the top of the list so they could say, ‘Oh, you know, those people are receiving services,’” Bailey said.
The Agency for Health Care Administration has a moratorium on new providers in Broward and Miami-Dade Counties until May because of the fraud investigations. But Angie Smith said children across the state are still sitting on wait lists while clinics grapple with getting new techs credentialed in other parts of Florida.
"It's the kids that end up suffering from that and (the state) can say that it doesn't affect them all they want but anybody that's in this field knows that that's a completely inaccurate statement,” she said.
The runaround
Smith said when you call the Agency for Health Care Administration to clarify credentialing information, you get 10 different answers from 10 different people. And when you submit paperwork, it's often bounced back to the clinic with a request for information that has already been provided.
"Sometimes we get lucky and they go straight through,” she said. “(Then) we complete the same exact paperwork for the next staff and they kick it back 30 times. And that's not an exaggeration; sometimes that happens.”
The Agency for Health Care Administration responded in an emial to those issues:
“The Agency processes applications in the order in which they are received. This applies to all provider types. When the Agency first implemented Behavior Analysis as its own provider type in 2017, it allocated significant additional resources to accelerate the application process. Since then, the Agency has returned to its regular processing timeframes. The application process includes multiple steps that an application must go through prior to being approved or denied.”
But those in the field, like Adrianne Smith at Creative Behavior Solutions in Largo, emphasize that's not the case. And because it's a struggle for new techs to get credentialed, the current techs with Medicaid approval are in high demand. She said larger companies are luring them away from smaller clinics with pay far beyond the industry average of $15 to $20 an hour.
"The highest we've seen is the salary for $95,000, which doesn't make sense,” Adrianne Smith said.
The fight against fraud
On top of that, clinics aren't entirely convinced fraud won't continue to find a way. Angie Smith said these techs cannot see what hours have been billed under their numbers in the Medicaid portal, opening the door for current or past employers to file for therapy they didn't do.
Melissa Hardee, a board certified assistant behavior analyst who has worked most recently in Vero Beach, echoes the sentiment that the state sometimes makes things unnecessarily difficult.
“One of the difficult things is I would say the (state) is sometimes not clear and they don't make it easy for you to really know sometimes what the rules are," Hardee said.
But, she said, it was high time for the state agency to crack down on fraud, which she claims is far more pervasive than anyone in the industry is willing to admit.
“I don't know what took them so long to even start paying attention to these services and to start regulating it,” Hardee said.
“I'm really hoping that they can somehow weed out the companies and the people that I have encountered in the field that have really turned me off and have made me constantly struggle. Should I even stay in this field? Is this actually a therapy worth fighting for?”
Moving forward
For now, some providers are considering giving up on Medicaid altogether.
"I don't want that to be our bread and butter anymore because you just never know what's going to happen.” Angie Smith said.
And with providers like her dropping out of the state Medicaid program, that could mean even longer wait lists and more communities where providers only serve children with private insurance.
Baily said the only way change is going to happen is if parents get involved.
But dozens of providers contacted by WUSF said they fear retribution from the Agency for Health Care Administration if they complain. Parents also fear the state will deny their children's therapy requests, they said.
Mallory McManus, spokeswoman for the Agency for Health Care Administration said those fears are unfounded.
“The Agency takes complaints submitted by providers seriously and does not punish providers who raise complaints about the enrollment process," McManus said in an emailed statement. “In fact, the Agency is in the process of fully reviewing all aspects of how providers interact with the Medicaid program, with a goal of significantly improving providers’ experience with Medicaid.”
Bailey said parents need to document every phone call and email to the Agency for Health Care Administration, then take it lawmakers. And if they don’t address it during the current legislative session, Bailey said parents have another option.
“This is ripe to me for a class action lawsuit where you get a dozen parents together and put them with an attorney and they tell their story and the next thing you know (the state) is now facing a lawsuit,” Bailey said.
