ABA Upcoding and Concurrent Billing: Technician Work, Analyst Claims

ABA 97153 97155 billing fraud concerns claims that misrepresent technician treatment as analyst work, bill for protocol modification that never happened, or charge improperly for overlapping services. A child can receive care while the bill describes a different service. For a technician, behavior analyst or billing employee, the important details are familiar: who worked with the child, what the analyst actually did, whether the session was individual or group, and which payer already paid. False health care claims charge taxpayer-funded programs for work the practice did not supply.

What Do 97153 and 97155 Describe?

Code 97153 describes individual adaptive behavior treatment delivered by a technician under qualified direction. Code 97155 describes treatment with protocol modification by a qualified professional, such as a board certified behavior analyst.

In its Indiana Medicaid audit, covering services in 2019 and 2020, the Department of Health and Human Services’ Office of Inspector General described the technician’s one-to-one treatment and the analyst’s work resolving problems with the treatment protocol while the child is present. The state used 15-minute billing units.

Technician group treatment has code 97154. Assessment and treatment-plan work belong under 97151.

Those distinctions matter inside a busy practice. A technician treating a group, an analyst changing a child’s protocol and a professional preparing an assessment report are doing different jobs. Moving the time onto a different code changes what the payer is being asked to buy.

When Can 97153 and 97155 Run at the Same Time?

The Indiana Medicaid audit describes concurrent 97153 and 97155 billing when a technician treats the child while a qualified analyst works to modify the treatment protocol. The Colorado audit, covering services in 2022 and 2023, describes the same pairing.

The analyst’s time, the child present and the protocol work give substance to the second claim. A schedule showing two employees in the same room answers only part of that question.

Protocol Modification That the Notes Say Never Happened

The auditors found claims for protocol modification whose session notes described leaving the protocol unchanged. In Colorado, one facility’s notes said:

The claim paid for a change. The note said to keep the treatment as it was. That contradiction gets much closer to the service problem than a calendar showing that an analyst attended.

The Colorado auditors also found protocol-modification claims for parent training, which the state did not cover during the audited period. Another facility used 97155 for a reassessment after it had already billed the maximum reassessment units. The notes described a standard assessment, data analysis and report preparation, work the auditors placed under 97151. The billed code changed after the assessment allowance ran out.

The guidance itself mattered. In both the Indiana and Colorado reports, the Inspector General said state guidance lacked sufficient detail and industry guidance may have caused confusion by allowing observation of a technician without implementing a protocol modification. The Inspector General warned that paying separately for that observation could duplicate the direction already built into technician treatment.

ABA Upcoding Patterns Inside the Practice

Technician Work Billed at the Analyst Level

Applied Behavior Center for Autism was part of a $2 million civil settlement announced in February 2023. The Justice Department alleged technician work billed at an analyst level, group care billed as individual care, concurrent or duplicate claims, and Medicaid billing for services already paid by another program.

The alleged substitution is specific: the business supplied a technician’s work and sought payment for an analyst’s service. That is why staffing and credential records belong beside the code on the claim. The child may have received treatment, but the payer was charged for a different level of work.

Colorado’s audit found a similar mismatch in its own payment review. At one facility, staff who were not board certified behavior analysts delivered services billed under 97155. The audit identified assistant analysts, registered behavior technicians and noncredentialed technicians performing work that should have been delivered by a qualified analyst. The worker’s identity changes the meaning of the claim.

Administrative Work Billed as a Child’s Therapy

Early Autism Project paid $8,833,615 in a civil settlement announced in August 2018. The government alleged that the company reserved therapy hours for regional administrative positions even when those employees did no work with the child being billed. The claims went to TRICARE and South Carolina Medicaid. A former employee brought the whistleblower case.

Regional Leads and Coordinators allegedly generated child-specific treatment claims through administrative work. The titles matter because they explain the substitution: time spent running the business became therapy attributed to a particular child. For someone who knows those employees’ actual duties, the difference can be visible long before anyone examines the billing code.

Group Sessions Billed as Individual Treatment

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

That pattern also appeared in the Applied Behavior Center for Autism allegations. There, the government said noncovered group services were billed as covered individual care. The children’s presence did not answer the payment question. The service format did.

A treatment schedule and the staff assigned to the session help show whether the claim’s individual-service description matches the care. An insider who knows which children were together can supply a fact that disappears when each child’s claim is read separately.

A Service Already Paid by Another Program

The Applied Behavior Center for Autism settlement also addressed allegations that Medicaid was billed for services already paid by TRICARE or Indiana CareSource, without disclosure. This part of the allegation concerned where payment had already come from.

The provider’s payment history matters alongside its clinical records. A session note can describe the treatment accurately while leaving the billing employee’s separate question unanswered: had another program already paid for that service? The government’s allegations connect the claim to both the work and the money received.

Rendering Identity Can Change the Payment

The person listed on a claim can carry a different payment rate from the person who treated the child. In a finding flagged for further review, Wisconsin’s audit of services in 2021 and 2022 identified focused-treatment claims listing a licensed supervisor or therapist when a technician had delivered the work. Those higher-level providers received more per unit under the payment rules described in the report.

State officials offered a possible explanation: some commercial insurers required the supervisor’s name, and Wisconsin required Medicaid claims to follow how the commercial claim had been submitted. The auditors checked that explanation and found that some of the affected children did not have commercial insurance.

Colorado exposed a different obstacle. Its claims generally identified a BCBA because technicians could not enroll as Medicaid providers, but there was no field identifying the technician who actually furnished the service. Some claims identified the facility instead, and some analyst claims named a different analyst from the one who delivered care. The Inspector General said those gaps limited the state’s ability to review service use.

That is why a rendering identifier needs to be read with staffing records, session notes and the payer’s reporting rules. The claim field, the person signing the note and the person doing the work can give different answers.

Billing Fraud, Unreasonable Expectations, or Both?

Both can meet in the same claim: pressure to hit billable-hours targets can lead to billing fraud when a practice charges for services or staff qualifications it did not supply. The cases above show the substitutions an employee may recognize in daily work.

Authorization records show what care the payer approved. Schedules and attendance show when the child and staff were expected or present. Payroll and credential records help identify the available workforce. Session notes describe the care, while the claim and payment records show what the practice charged and who paid. We examine those records together with the insider who understands how the practice operated.

An authorization approves care in advance. The treatment record still has to account for the service billed afterward. The insider’s contribution is often knowing why those records diverged and who decided how the work would be billed.

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

What the ABA Audits Found

The Inspector General estimated improper fee-for-service Medicaid payments for ABA of at least $56.5 million in Indiana, $18.5 million in Wisconsin and $77.8 million in Colorado. The findings included unsupported service codes, documentation problems and work performed without the required qualifications. These were payments for care that failed the programs’ requirements.

Indiana’s audit also found documented nap time included in paid ABA units. At one facility, a child’s 45-minute nap was not deducted from the time billed. Colorado’s auditors likewise found documented naps included in paid units. The practice charged for therapy while the child slept.

Indiana’s auditors also found session notes signed by someone other than the person who furnished the service, sometimes months after the care and after the claims had gone to Medicaid. A supervisor’s signature can make a record look complete while leaving the worker’s identity unresolved. The staffing record and the original session note help answer who did the work.

You Know Who Did the Work

If you know why your practice’s claims describe a different worker or service, speak with our whistleblower experts about the ABA billing you have seen. We work with you to build your strongest ABA billing whistleblower case around the treatment, the claims and the decisions behind them, bringing in healthcare fraud whistleblower lawyers who understand ABA billing. We stay beside you through the case, with your knowledge of the practice at the center of the work.