Good Shepherd Catholic School: The TRICARE Settlement Over Group Therapy

In the Good Shepherd Catholic School fraud case, the Oklahoma City nonprofit paid $354,000 to settle allegations that it billed TRICARE for one-on-one autism therapy while providing group services. The allegation turns on something a therapist, scheduler or biller can recognize: who was working with each child when the school billed for individual care.

The Defense Criminal Investigative Service investigated the case. The Justice Department’s Western District of Oklahoma office announced the settlement on April 25, 2023.

Good Shepherd Catholic School Inc. is a private educational institution serving students with autism and other neurological disorders. Its program includes applied behavior analysis therapy for students diagnosed with autism spectrum disorder, and it submitted claims for that therapy to TRICARE, the Department of Defense Military Health System’s health care program.

Group ABA Billed as One-on-One Treatment

The government alleged that Good Shepherd knowingly submitted false ABA claims from May 13, 2013, through December 20, 2016. According to the settlement announcement, the services covered by those allegations took place in groups even though TRICARE required one-on-one treatment.

The department described the payment requirement in concrete terms: a TRICARE-authorized provider delivering ABA to a TRICARE beneficiary on a one-on-one basis.

Different employees see different parts of that comparison. A therapist may know which children shared a session. A scheduler may know whether staff assignments matched the billed treatment. A billing employee may know how those assignments were translated into claims.

Why the Service Format Matters

ABA billing distinguishes more than whether a child attended. For example, Indiana’s ABA payment schedule effective January 2024 distinguishes technician-delivered individual treatment, technician group treatment, qualified-practitioner treatment and caregiver guidance. These service descriptions tell the payer what work it is being asked to fund and who performed it.

The schedule separates assessment and treatment-plan work from treatment itself. It also distinguishes a technician’s work with a child from a qualified practitioner’s work modifying the treatment protocol. Guidance for a family or caregiver has its own description, including a separate category for guidance involving multiple families. For someone working in ABA, these are recognizable parts of the day: assessing, treating, changing the plan and guiding a caregiver. Billing assigns a description to each kind of work.

The same schedule also includes group treatment by a qualified practitioner and technician support for assessment under qualified direction. Group size, the worker’s role and the purpose of the session are separate parts of the service description.

In the government’s account, TRICARE was billed for individual attention while children shared a provider’s time. A school’s attendance record can show a child was there. The treatment record and claim have to account for what happened while the child was there.

Authorization and the Session Actually Delivered

An authorization does not show who delivered the billed session or how much treatment the child received.

For an insider, the useful detail may be a staff assignment that does not fit an individual session, or a claim description that conflicts with the treatment note. We work through the connection between those records and the account of the person who saw the care delivered.

Other ABA Providers Faced the Same Billing Allegation

The individual-versus-group distinction also appeared in settlements involving Autism Concepts and ABA Programming. Each involved allegations about how autism treatment was represented for payment.

Autism Concepts and Simultaneous Group Services

Autism Concepts Inc. and its director agreed to a $300,000 settlement, announced in October 2019, over allegations that TRICARE claims represented individual ABA treatment while children received simultaneous group services.

That is the closest comparison to Good Shepherd: the same payer and the same alleged substitution of group treatment for the individual service billed. The operational question concerns children treated together and claims describing their care separately as individual treatment. Someone present for the sessions may understand that discrepancy before ever seeing a payment total.

ABA Programming and the Work Behind the Claim

In the settlement involving ABA Programming Inc. and Applied Behavior Center for Autism, the government alleged that noncovered group ABA was billed as covered individual care.

Whistleblower Cases About ABA Billing

An ABA billing qui tam case connects the claim to the session and to what the provider knew about the difference. In Good Shepherd’s case, the government expressly alleged knowing submission of false claims. For someone who has seen group treatment represented as individual care elsewhere, knowledge of how that representation reached the payer is central to the account they bring us.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Saw How the Sessions Ran

If you saw group ABA billed as individual treatment, talk with our whistleblower experts about the sessions and claims you know. We work alongside you to build your strongest whistleblower case around that difference and bring in healthcare fraud whistleblower lawyers who understand ABA billing and government payment programs. Your knowledge of the care stays at the center of the case we pursue together.