Medicaid Autism Services Fraud Defense
Defense Counsel for Healthcare Providers Facing Allegations of Improperly Billing Medicaid for Autism Therapy
Many children and families rely on Medicaid payments to cover the costs of treatment for autism. Unfortunately, due to widespread fraud resulting in hundreds of millions in improper payments annually, the federal government aggressively targets healthcare providers suspected of improperly seeking Medicaid reimbursement. If you are facing an audit, investigation, or charges involving allegations of Medicaid autism services fraud, you should engage experienced defense counsel right away.
Our lawyers defend healthcare providers accused of receiving improper Medicaid payments for autism therapy and other autism services nationwide. If your practice is facing scrutiny for receiving potentially improper payments, our lawyers can help ensure that you do not face unnecessary and unwarranted consequences. We have extensive experience defending clients against accusations of healthcare fraud under Medicaid and other government programs, and we can use our experience to help protect you by all means available.
Healthcare providers’ autism-related billings under state Medicaid programs have come under scrutiny in recent years. Many healthcare providers have faced invasive audits and investigations focused on assessing their compliance with the relevant federal and state requirements for billing for services such as:
- Autism diagnosis
- Autism therapy
- Autism treatment plans
- Behavioral intervention services
- Communication and social skills development
- Early intensive developmental services
- Housing stabilization services
- Services provided at autism centers
- Other services focused on building new skills and managing behavioral challenges
Along with representing autism centers, applied behavior analysis (ABA) providers, and other healthcare providers, we represent transportation providers and other entities as well. We defend entities and individuals against allegations including (but not limited to):
Assessment and Diagnosis Fraud
When billing Medicaid for autism assessments and diagnostic services, providers must fully comply with the relevant Medicaid billing regulations. We are seeing an increasing number of enforcement actions targeting assessment and diagnosis fraud—with auditors, investigators, and prosecutors focusing on missing session notes and other missing documentation, autism diagnoses for nearly every child assessed, and various other red flags for autism fraud schemes.
Applied Behavior Analysis (ABA) Therapy Fraud
Applied behavioral analysis (ABA) is an essential form of care for children with ASD. When ABA is a medically necessary service, it is considered a form of proper care, and eligible healthcare providers can bill Medicaid for services provided by therapists and behavioral technicians. However, auditors and investigators are now questioning whether ABA is a necessary and appropriate form of patient care in many instances, and this presents substantial risks for providers who may be accused of failing to exclusively bill Medicaid for “medically necessary” services.
Service Limit Fraud
Autism therapy and other autism-related services covered under Medicaid are subject to service limits in many states. Consistently billing at these service limits can also be a red flag for fraud. We are increasingly seeing federal oversight focused on service limit fraud as well, with federal authorities including the U.S. Department of Justice (DOJ) and U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) focused on ensuring that Medicaid spending does not cover services that were not actually provided.
We are seeing a large volume of Medicaid fraud investigations targeting illegal referral fees, rebates, and other “kickbacks” prohibited under federal law. While these fees can provide powerful incentives for making referrals, they are strictly prohibited in many circumstances. We defend healthcare providers and other entities accused of violating the federal Anti-Kickback Statute, as well as physicians and related entities accused of violating the federal Stark Law (or “Physician Self-Referral Law”).
Medicaid Billing Fraud and Other Violations
Along with these issues, allegations of Medicaid billing fraud and other violations remain common as well. While state agencies are generally responsible for administering Medicaid programs, federal authorities generally take the lead on prosecuting Medicaid fraud cases. With the reported substantial increase in autism prevalence and related services provided to members of vulnerable populations across the United States, this is a priority enforcement area for the DOJ and HHS OIG.
We Represent Healthcare Providers in All Medicaid Autism Services Fraud Matters
Our Medicaid fraud defense lawyers represent healthcare providers in all enforcement matters related to their program billings for autism services. We have extensive experience protecting clients in matters including:
Audits Conducted By Fee-For-Service Medicaid Auditors
We routinely defend healthcare providers during audits conducted by fee-for-service Medicaid auditors. These are private contractors that work with the Centers for Medicare and Medicaid Services (CMS)—and that are financially incentivized to allege improper billings. Aggressive, misguided enforcement and inconsistent oversight are significant issues under CMS’s Medicaid audit regime, and many providers find themselves facing unwarranted allegations of billing noncompliance.
Investigations Conducted by the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG)
The HHS OIG conducts targeted investigations focused on uncovering fraudulent billings for Medicaid autism services. From consistently billing at service limits to billing at standardized rates, the HHS OIG relies on a variety of red flags to determine when scrutiny may be warranted. Similar to auditors, the HHS OIG relies on available data accessible through the Medicaid system as well as on-site examination of providers’ billing records to assess whether civil or criminal fraud allegations may be warranted.
Along with HHS OIG investigations, we defend healthcare providers during investigations conducted by other federal and state authorities as well. This includes investigations conducted by the U.S. Department of Justice and state Medicaid Fraud Control Units (MFCUs), among other entities. These investigations can present substantial risks, and targeted providers must take a proactive approach to defending themselves by all means available.
Civil Enforcement Proceedings
Unintentional Medicaid billing violations related to autism services can expose providers to civil enforcement proceedings. In these proceedings, providers can face fines, recoupments, treble damages, loss of Medicaid eligibility, and other steep penalties. If your practice or business is facing a civil enforcement action following a Medicaid audit or billing fraud investigation, our lawyers can work to steer the action toward a favorable resolution.
Criminal Medicaid Fraud Cases
We defend healthcare providers and other clients in criminal Medicaid fraud cases as well. Whether you are being accused of perpetrating an isolated scheme to improperly bill Medicaid or you are being accused of playing a role in a larger fraudulent enterprise, we can use our experience to help protect you by all means available.
FAQs: Defending Against Allegations of Medicaid Autism Services Fraud
When is billing for applied behavior analysis provided to children diagnosed with autism considered fraud?
Billing for applied behavior analysis provided to children diagnosed with autism is considered fraud when providers do not comply with the relevant Medicaid billing guidelines. Depending on the circumstances, this could involve anything from providing services to children who are not covered under Medicaid to exceeding your state’s service limits.
Healthcare providers that have received unfavorable Medicaid audit determinations have the right to file an appeal. If you need to appeal the outcome of a Medicaid audit focused on your practice’s billings for autism services, our lawyers can guide you through the process.
Why is my autism practice facing a Medicaid audit?
Healthcare providers that provide autism therapy and other autism-related services can face Medicaid audits for various reasons. In some cases, family members may raise concerns about billing fraud. In others, audits may be the result of random selection. Autism services fraud has received a significant amount of media coverage in recent years; and, as a result, uncovering this type of fraud has become a top priority for the government.
What is the difference between a Medicaid audit and a Medicaid fraud investigation?
Medicaid audits are conducted by fee-for-services contractors working with CMS, while Medicaid fraud investigations are conducted by federal authorities and state Medicaid Fraud Control Units (MFCUs). While there are other differences as well, audits and investigations ultimately present similar risks—and this means that targeted providers need to prioritize their defense in all scenarios.
Yes, if you are facing scrutiny related to your practice’s Medicaid billings for autism services, you should engage experienced defense counsel promptly. This is a high-risk scenario, and you will need to defend yourself effectively to avoid unnecessary and unwarranted consequences.
Schedule a Free and Confidential Consultation with a Medicaid Fraud Defense Lawyer at Oberheiden P.C.
If you are facing a Medicaid audit or investigation—or if you are facing civil or criminal allegations of Medicaid autism services fraud—we encourage you to contact us promptly for more information. To speak with a senior Medicaid fraud defense lawyer at Oberheiden P.C. in strict confidence, call 888-680-1745 or request a complimentary initial consultation online now.
Additional Medicaid Pages
- Medicaid Fraud Lawyer
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- Medicaid Preventive Health Care Fraud Defense
- Medicaid Dental Care Fraud Defense
- Medicaid Hospice Benefits Fraud Defense
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- Medicaid Mandatory Benefits Fraud Defense
- Medicaid Early and Periodic Screening Fraud Defense
- Medicaid Behavioral Health Services Fraud Defense
- Medicaid Fraud Defense for Hospice Businesses
- New York Medicaid Fraud Defense
- California Medicaid Fraud Defense
- Minnesota Medicaid Fraud Defense
- Telehealth Medicaid Fraud Defense
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