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Autism Provider Challenges State Over Medicaid Verification System

The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

Stuart-based Positive Behavior Support alleges that the electronic visit-verification system is changing behavior-analysis claims after submission and making them invalid.

The state’s largest provider of autism services has filed an administrative complaint against the Medicaid program, alleging that an electronic visit-verification system being tested in eight Southeast Florida counties is a roadblock to reimbursement and an overstep by the Agency for Health Care Administration.

Stuart-based Positive Behavior Support alleges that the so-called EVV system or someone with access to it is changing behavior-analysis claims after submission and making them invalid.

“The only opportunity that providers such as (Positive Behavior Support) have to correct such an improper modification prior to the reimbursement filing deadline is to personally monitor these submissions and attempt to manually restore them within the EVV system to their original status,” attorneys for the company wrote in the complaint.

“Remedying errors that the system itself has caused falls outside of the agency’s promulgated requirements for providers and results in improper delay in reimbursement for their services.”

A state manual makes clear that providers can fix and resubmit claims for payment so long as it’s done within a certain time frame. But attorneys for Positive Behavior Support allege that the EVV system robs providers of that right because claims that are fixed and resubmitted are being flagged as duplicates of the originals and are being denied.

“This is not a problem that is specific to PBS. Rather, other similarly-situated providers are experiencing the same problems with the EVV system, showing it to be an industry-wide problem,” attorneys wrote.

Applied behavior analysis is a type of therapy for people with autism.

Worried about potential fraud and abuse, the state took steps in recent years to increase oversight of applied behavior analysis providers, including turning to an electronic visit-verification system that details issues such as what and when services were provided.

The electronic system was piloted in Southeast Florida but is slated to be used statewide.

Positive Behavior Support wants an administrative law judge to issue an order finding that the system imposes requirements and burdens beyond those in the manual, that the effects of the system amount to unpromulgated rules and that the agency be ordered to “immediately cease reliance upon them.”

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