Fraud, Waste, and Abuse Prevention
Purpose
This policy sets the standard for preventing, detecting, and correcting fraud, waste, and abuse in billing, clinical documentation, and the use of organizational resources. It exists so that every claim ABAS submits is accurate and supported, and so that funds entrusted to ABAS are used only for their intended purpose.
Scope
This policy applies to all ABAS employees, including clinical, billing, and administrative employees who create clinical documentation, submit or support claims, handle organizational funds, or interact with payers. It covers all services billed by ABAS and all use of ABAS resources. It applies whether a violation is intentional or results from error, carelessness, or neglect.
Definitions
| Term | Definition |
|---|---|
| Fraud | Knowingly submitting, or causing the submission of, false or misleading information to obtain a payment or benefit to which ABAS or an individual is not entitled. Fraud requires intent. |
| Waste | The overuse, careless use, or mismanagement of resources, including services or supplies that are not medically necessary, that results in unnecessary cost to a payer or to ABAS. Waste does not require intent. |
| Abuse | Practices that are inconsistent with sound fiscal, business, or clinical standards and that result in unnecessary cost, improper payment, or services that fail to meet professionally recognized standards of care. |
| Medical Necessity | The standard, defined by payers, under which a service is reasonable and necessary to diagnose or treat a member's condition and is consistent with accepted standards of ABA practice. |
| Upcoding | Billing for a service at a higher level, intensity, or duration than was actually delivered or documented. |
| Overpayment | Any payment ABAS receives to which it is not entitled, whether through error or otherwise, that must be reported and returned to the payer. |
Policy Statement
5.1 Commitment
ABAS prohibits fraud, waste, and abuse in all forms. Every claim ABAS submits must be accurate, supported by contemporaneous documentation, and for a service that was actually delivered and medically necessary. This commitment applies to all employees at every level of the organization.
5.2 Accurate Billing and Documentation
Employees must bill only for services actually rendered and must document each service at the time it is delivered. Documentation must identify the member, the rendering provider, the service delivered, and the start and end times, and must support the medical necessity of the service under the member's authorized treatment plan. Employees must not upcode, bill for missed or cancelled sessions as if delivered, or alter records after the fact except through a dated and attributed correction.
5.3 Prohibited Conduct
The following are prohibited. This list is illustrative, not exhaustive:
- Submitting claims for services not rendered, or for more time or intensity than was delivered.
- Falsifying, backdating, or altering clinical or billing records.
- Misrepresenting the credentials or identity of the rendering provider.
- Sharing, copying, or applying another person's signature or login credentials.
- Billing for services that are not medically necessary or not supported by an authorized treatment plan.
- Using ABAS funds, property, or paid time for personal benefit.
5.4 Anti-Kickback and Referrals
ABAS prohibits offering, paying, soliciting, or receiving anything of value to induce or reward the referral of business. This requirement reflects the federal Anti-Kickback Statute and applies to relationships with referral sources, vendors, and other providers. Questions about a specific arrangement must be directed to the Compliance Officer before ABAS enters into it.
5.5 Overpayments
An employee who identifies a payment ABAS was not entitled to must report it to the Compliance Officer promptly. ABAS will investigate, document, and return confirmed overpayments to the payer within the timeframe the payer requires. Returning an overpayment is required regardless of whether the cause was error or misconduct.
5.6 Non-Retaliation
ABAS will not retaliate against any person who, in good faith, reports a suspected violation of this policy or participates in an investigation. The protections and reporting paths in POL-003 (Compliance Reporting, Investigation, and Resolution) apply to all reports made under this policy.
Procedures
Responsibilities
| Role | Responsibility |
|---|---|
| All ABAS Employees | Deliver and document services accurately and at the time of service. Report suspected fraud, waste, or abuse through established channels. Complete required training. |
| Billing & Recovery Specialist | Review claims against supporting documentation before submission. Identify and escalate billing irregularities and suspected overpayments to the Compliance Officer. |
| BCBA Team | Verify that services billed are medically necessary and supported by the member's authorized treatment plan. Confirm that documentation meets clinical and payer standards. |
| Compliance Officer | Maintain this policy, oversee FWA monitoring and audits, investigate reports, coordinate return of overpayments, and report results to the Compliance Committee. |
| Executive Director | Ensure adequate resources for FWA prevention and support enforcement and corrective action. |
Steps
- Employees document each service at the time of delivery, capturing the information required in Section 5.2.
- The Billing & Recovery Specialist reviews claims against documentation before submission and holds any claim that is not fully supported.
- The Compliance Officer conducts periodic claim and documentation audits as scheduled in the annual compliance work plan.
- When an overpayment is identified, the Compliance Officer documents it and ABAS returns it to the payer within the required timeframe.
- When fraud, waste, or abuse is suspected, the matter is reported and handled under POL-003 and its Compliance Ticket Management SOP.
Training Requirements
All ABAS employees must complete fraud, waste, and abuse awareness training during onboarding and at least annually thereafter. Billing and clinical employees must complete role-specific training on documentation standards, medical necessity, and accurate coding. The Compliance Officer tracks completion of this training and reports completion rates to the Compliance Committee as part of regular compliance reporting.
Reporting and Enforcement
Employees who suspect fraud, waste, or abuse must report it through the channels described in POL-003 (Compliance Reporting, Investigation, and Resolution), including the anonymous web form and the compliance ticketing system. Reports are investigated under POL-003 and its Compliance Ticket Management SOP. A confirmed violation may result in corrective action up to and including termination, restitution of any improper payment, and referral to the relevant payer or program, law enforcement, or other authorities where required by law. ABAS will not retaliate against any person who reports a concern in good faith.