The Shape of Behavior: Rendering Identities and Excessive ABA Hours

The former owner and sole shareholder of The Shape of Behavior paid $2,729,083 to resolve allegations of improper TRICARE applied behavior analysis billing. The government alleged that claims named the wrong rendering providers, lacked support in medical records or billed excessive hours for individual providers. For someone who knows the treatment schedule and the people doing the work, those allegations reach directly into the working day: whose time became whose claim.

The Shape of Behavior was a Texas-based provider of therapy for children with autism. The U.S. Attorney’s Office for the Southern District of Texas announced the settlement on March 23, 2021. The fraud case concerned claims from nine separate locations for children covered by TRICARE, the health care program for uniformed service members, retirees and their families. The alleged billing put taxpayer money meant for those children’s treatment toward claims that misrepresented the care.

The TRICARE ABA Claims the Government Challenged

The government alleged problems with provider identities, medical-record support and hours billed on particular service dates.

Rendering Providers Who Did Not Match the Claims

The government alleged that The Shape’s claims misrepresented the identity of the providers who actually rendered the services.

A billing employee sees the provider identity submitted to the payer. A therapist or supervisor may know who actually worked with the child. We put the claim beside the treatment: the worker, the child, the service and the date.

Applied behavior analysis billing distinguishes a technician’s individual treatment from a qualified practitioner’s assessment, treatment-plan work or treatment with protocol modification. The Washington billing guide and Indiana payment schedule illustrate those distinctions in state Medicaid programs. Both use 15-minute units, with payer-specific rules governing how the work is billed. Those distinctions give a rendering identity substance: the claim identifies whose work the program is being asked to pay for. We connect that identity to the actual task and the worker who performed it.

Claims the Medical Records Could Not Support

The government also alleged that medical records could not substantiate claims submitted to TRICARE. The allegation concerns the support for the bill: whether the treatment record backs the service the company charged to the program.

For an insider, the connection between a session note and a claim can be more revealing than either document alone. We examine what the bill represented about the service and its duration, then what the treatment record says about that child’s care on the same date.

Excessive Hours on Individual Service Dates

The hours allegation concerned individual providers billing excessive hours on individual dates. We examine the provider’s working day. A clinic’s overall activity can obscure which worker supposedly delivered each session.

Schedules, attendance and contemporaneous treatment notes let us examine that working day alongside the billed hours. An employee who knows the schedule can explain the difference between the sessions that took place and the hours submitted for payment.

In time-based applied behavior analysis billing, authorized hours can become a ceiling that a practice treats as delivered care. That is the broader billing problem: approval for a course of treatment becomes a claim for sessions the attendance or staffing cannot support. We examine the authorization alongside the actual service, the rendering worker, the treatment note and the paid claim.

Humana Military Uncovered the Claims

TRICARE’s own managed care support contractor, Humana Military Program Integrity, uncovered the alleged improper claims. The Defense Health Agency’s Office of Program Integrity, the Defense Criminal Investigative Service and Humana assisted in the joint investigation.

The Billing Pattern in Other ABA Cases

Other applied behavior analysis settlements show how provider identity and billed hours can diverge from the work performed.

In its March 2017 settlement with Exemplary Behavior, the government alleged that the company billed TRICARE for services not rendered by the billing provider. It also alleged double billing, group therapy billed as individual therapy and services that were never provided. The provider’s identity and the session’s format were separate representations on the bill. Someone who worked in the room could know both.

The government alleged that Early Autism Project billed South Carolina Medicaid for therapy by employees doing administrative work instead of working with the child, and allowed therapists to inflate hours billed to TRICARE and South Carolina Medicaid for services not provided.

Across these cases, the useful knowledge is concrete: who did the work, what work it was and what the payer was told.

What Your View of the Practice Can Add

The Shape case centers on information that sits across treatment and billing: the rendering worker, the record of care and the hours claimed. If your work gives you a view of a mismatch between them, our whistleblower experts can assess how that knowledge fits the paid claims and the decisions inside the practice.

The detail may be how provider identities reached the billing system, how actual sessions differed from recorded hours or how administrative work became treatment on a claim. Those are specific questions about a business’s conduct, tied to the people whose care the program was paying for.

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

You Know Who Worked Those Hours

If the provider identities or hours on an applied behavior analysis claim contradict the care you know was delivered, talk with our whistleblower experts about what you saw. We build the case with you, bring in healthcare fraud whistleblower lawyers who understand therapy billing and stay beside you through the pursuit of a recovery.