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Audit Anxiety in ABA Businesses: Lessons Every Owner Needs to Hear · ABA Business Leaders

• speaker-0: went to the worst. I'm gonna get audited. They're gonna find all kinds of problems. My company's gonna go under. My staff aren't gonna be supported. I'm gonna lose the house. Like, kids aren't gonna have anything anymore. speaker-1: Remember one where they said we owed $140,000 and then we sent in additional information and they said, my bad, don't worry about it. These are the things that they will try to do. Just be aware of that. Welcome to ABA Business Leaders brought to you by 3PiSquared, where we discuss topics on how to create and grow an ethical and sustainable ABA practice. speaker-2: Whether you're starting, scaling, or thinking about selling your business, we're here to share insights, stories, and strategies to help you on the journey. speaker-1: we owned a successful ABA practice for over 10 years. speaker-2: And now we help other ABA business owners do the same without all the chaos. speaker-1: Stick around, you're in the right place. speaker-2: Hello everyone, welcome to ABA Business Leaders podcast brought to you by 3Pi Squared. I'm April. And today with us, we have a good friend to the podcast. If you've been around for a little while, you know her already, Alicia Barrett. Welcome, Alicia. Of course. Thanks for coming on. today we're just, you know, we're going to chat about audit anxiety. There's no formal fancy introduction to this. speaker-1: I'm Stephen. speaker-0: Hi, thanks for having me. speaker-2: podcast today, more of like, you know, Alicia was found herself in a situation this week, ⁓ where audit anxiety showed up for sure. And just like a lot of times when I have these conversations with business leaders, then I realized, you know what, you're not the only one. if there's one person who's been in this situation, and I know we've been in this situation, then there are others. So I'm like, hey, you want to bring this conversation on air? And she said, yes. speaker-0: She said yes, yay! speaker-2: ⁓ So I guess to set up the story of it and Alicia can fill in, but Alicia I saw on her, she had posted on some of the like social media groups, right? ⁓ Kind of, would say, I think it's fair to say spiraling about like receiving a letter and not being able to access the letter yet, but it was from an insurance company. And then it was like, ⁓ my gosh, is this the audit? this, is it now? Is this when it happens? And so myself and many others in the communities. So out there in socials, we're like, it's okay, it's okay. And then I reached out to Alicia and checked on her the next day because those moments are terrifying and terrible. And sometimes the next day we can feel like all kinds of feelings anyways. And so that's like I said earlier, that's what brought us to having this conversation on air. So Alicia, how is that spiral? ⁓ my gosh. speaker-0: Cool, so I'll kind of give a little background information. I'm in the process of preparing to get a network with Optum. So there's that audit piece there. And I'm like, crap, I have a lot of the pieces, but do I have all the pieces? I don't know. Let's go through this, right? So there's that. And then ⁓ I also just went to a state-specific audit training. Literally last week. So audits on my mind and then I get a certified letter that I can't access and I'm like, ⁓ my gosh, I literally spiraled so fast. It was uncontrollable. ⁓ I'll be a little vulnerable here and just say like, my mind went to the worst. Like I'm to get audited. They're going to find all kinds of problems. They're going to tell me I'm being fraudulent. My company is going to go under. My staff aren't going to be supported. I'm going to lose the house. Like, kids aren't going to have anything anymore. I went under. I was on the struggle bus. And a lot of people, it's hard to take. Like, we hear you. Like, I understand, but don't stress out, don't freak out. Like, it could be lots of things. I intellectually understand that and I intellectually know that, but my mind is telling me, no, girl, this is the audit. This is really like, so I had to like, you know, I don't know, there wasn't an easy way to get out of that spiral. ⁓ It was, it was really hard. ⁓ I didn't sleep that night. The next morning I went to the post office to get this certified letter and I almost had a panic attack, ⁓ almost crying before I walked in. I was shaking, not knowing the whole way driving there. was prep talking, like, OK, if it's not it, then you just provide them with what they're asking, only what they're asking. That's it. Don't do anything else. I was just prepping myself. But still in the back of my head, I was still like, no, this is not going to be OK. Thankfully. It wasn't an actual audit letter. So now I can look at it and kind of laugh. But like that also sparks like, okay, like this is a real thing. Like, you know, I know that I am that I'm behind the eight ball of being prepared for an audit, right? Emotionally, maybe actually physically, I don't know. ⁓ But then it's also like, there's a lot of unknowns, a lot of misconceptions, a lot of. ⁓ I guess misinformation about what audits truly are. And you hear all the big things. So they can look at all the things. They can look at everything, environment and staff files and this and that. And how can you keep track of all the things? And, you know, I'm the business owner, the only BCBA, like I'm bootstrapping it over here. Like, I don't know, there's probably things that are missing. ⁓ And yeah, it's just a lot to think about. And like, where do you even start? to be ready, right? So yeah, there it is. speaker-2: Yes, yes. ⁓ Thank you so much for being vulnerable and for sharing truly because I am certain there are many people listening to this right now who are feeling your pain. They're yes, they've either said, yes, I've been there, or they're like, yes, I'm having the same worries about my first audit because it's going to happen. speaker-1: I mean add jail to the list, right? I'm gonna be a criminal. They're gonna put me on the news and like speaker-2: Yeah, because we had we had a letter that came in about an audit and they were like accusing us of fraudulent, you know, stuff. And we were like, we didn't this is no like we were like 100 % certain that speaker-1: Well, that was the findings. So they wanted to see some sessions and so we sent them over and then they came back and said we were obviously committing fraud because they googled the bell times of the schools and we couldn't be seeing these kids because they're in school. speaker-2: So we know for certain in Virginia, was like the, can't remember what it's called now, but you could pull your kid out for ABA with no like, with no consequence. And we know that in the treatment plan, the BCBA had written it under like a description of like why we're seeing the school age child during the school day at home. And anyways, we knew like that was probably one of the most concrete, like we know we did nothing wrong. We're right. And we were both spiraling and Stephen was like, I remember, think that's what I don't, it might've been a different conversation, but I think it was this one where you were like, well, you visit me in jail, you know, and then I was like, well, we're both be in jail because we both own this place. Right. And we had like, well, this was like a toddler at the time when we were like, who's going to raise our child? Yeah. I mean, it's so easy to it's scary stuff. And I'll be like my mentor, the, the, my first ever ABA mentor back in the. speaker-0: Thanks. speaker-2: early to mid 90s, who I thought the world of. And it was this amazing person. And I learned so many cool things about how to deliver ABA ⁓ in a compassionate, anyways, just amazing person. Not that long ago, I came across an article that she's in federal penitentiary. She's in jail somewhere for speaker-1: fraud speaker-2: And the same company I worked for like way back when right before there was even insurance issue. That was even a thing. Yeah. But anyways, so that like personally brought it back home to me. like, ⁓ like just being a good person is not going to keep you from like, you know, and at the time we were we were building these policies and procedures and learning. speaker-1: of dollars. speaker-2: what's on we were and we've shared this numerous times that we worked with an attorney. ⁓ She's now a judge, right? ⁓ Jody Bauer and then her associate and who is now taking over her firm, Kim Mack. Now you have me messing her name up. Steven's always messing her name up, but I'm like, ⁓ it's Kim Mack. Anyways, and so we learned so much from those two individuals. In fact, Kim's been on one of our past podcasts. It might be a good if you haven't listened to that one, Alicia, might be a good one to listen to. speaker-1: Rosenberg. speaker-2: talking about on its way. Anyways, like it's just such a real thing in the field and it's just prevalent. You hear it in the news and it really does happen. People for whether they just don't know enough of what they're doing or people are intentionally trying to cheat the system, know, I think both happen. speaker-1: Yeah, yeah, I mean, I like to say often, like, I don't believe any BCBA wakes up in the morning and says, let's commit some fraud, right? Like, I just, have to believe that that's true for 99.9 % of us. It's just making a mistake, an honest mistake can happen. ⁓ You know, and, and there were times where we would get a finding from an audit where they said we would, we owed money. And I can remember one of them was we had to pay them $5,000. And I was like, no, I know we did this, right? I am not paying this. And we probably spend $10,000 in attorney fees to get the acknowledgement that we did nothing wrong and we didn't pay them a dime. So I would much rather pay for, it's like a, what is it? Like it's- Rotator? No, no, no. Like it's the, I've lost my words cause I have anxiety over something else right now. But- you know, it's the principle of the matter for me, right? Like I'm not going to, I'm going to do my best to do this right. And I'm not going to lie and say I did something wrong when I know I didn't do something wrong. Right. And so that, that was important to me. again, would have cost us less had we just said, fine, take our money. And, but yeah, it's, it's really important. It was important for me. speaker-2: I mean, we got letters like saying that they were going to recoup hundreds of thousands. speaker-1: That first one. yeah, like I still like even when you sent that Facebook post out, I was like, I don't know if it's PTSD, but I was like, Oh man, like I just like, I start to sweat and I to. It's a real, it's a real. speaker-2: It's real. I've talked to some business owners though, and I think I might have even been in this camp a little bit, and maybe it was because I knew I had Steven, the two of us, right? We were together in this. And that was way back when in our marriage where we didn't quite communicate the way that we've learned to communicate. But part of me went the other way. I just turned off the emotion and I was like, well, nothing I can do about it now. If it's going to happen, going to kind of went the other. of direction of like almost ignoring it. Like, ⁓ if I don't check the mail, then I won't ever get audit paper in the mail. speaker-0: I'm not going to lie, thought crossed my mind. Because not only was it certified and I missed, but it went to my old, like an old address that's not even connected to the business anymore. like, like, okay, well, you missed me. So sorry about your luck. speaker-2: I know right speaker-0: And then I was like my conscience couldn't like I wouldn't be able to live with that so speaker-2: Yeah, the anxiety would have been like gnawing at you until you found out like when are they gonna come show up at my door to arrest me? speaker-1: Like I'm like the person right I have not committed any crimes right and but I've had to get multiple background checks and even when I do a background check I am like some part of me is like they're gonna find that you committed a crime and you went to jail like and it's like dude Like I'm arguing with myself. I know I was never in jail really I've never come but I would still panic about what if they find something on my back so like that's just the way I roll right with my imagination and ⁓ like getting a handle on that is nearly impossible, right? It just, kinda have to just let it come in waves, right? Cause it'll die down, right? Maybe I've run out of, ⁓ mental energy to maintain that level of anxiety. then like, I'll think, okay, maybe it's over and then you'll just get a hint of it. And then your heart, I can feel my heart. It's like kind of like the sharp pressure and then I feel the thought and it's terrible. ⁓ speaker-2: I mean, my advice too is like, okay, in these moments, this is my cognitive advice, right? This is like my, yeah, my like stable cognitive person can talk to your stable cognitive person while the rest of ourselves are like, right? Like crazy freaking out, all kinds of worst case scenarios. But yeah, it's like, okay, I get that in this moment, I could pause and I can like remind myself of what I am and control up and I can like, first of all, I can just ground and feel my body and like, like Steven said, like let, Let this be here and sit with it while it's here. Blah, blah, blah, blah, blah. And I will say to some extent, Stephen's probably I can almost guarantee Stephen's going to disagree with me, but to some extent it does get easier. And I think part of it getting easier as was as I learned more about it. And it wasn't this like big, crazy, scary thing that's going to happen out of nowhere that I have no control over and is going to be this big unknowns because in my personal, my. The way my anxiety shows up is strongly due to unknowns or things I can't see. What's on the other side of that hill? What's past the horizon? Like you're out in a boat in ocean. You're like, what's past the horizon? We're just going to fall like out of nowhere. Right. So and and so those speaker-1: flat earther? No I'm not a flat Secretly a flat earther. speaker-2: No, but but so I have this actually I actually asked chat GBT I can't remember what the name of it is. was like trying to as Google or not Googling but I was like, what do call that when you ask AI? Is there a term for that yet? Like if you ask AI for something versus Googling, do you still call it speaker-1: yeah, no, I mean, I say I'm going to ask Chatty, but. speaker-2: So I asked like I said, okay I have this these fears and they all seem related and I don't know what they're called and I was like I have a fear of the dark I have a fear of like deep ocean water that you can't see the bottom or even water you can't see the bottom of it I have a fear of like what's on the other side of the tall hill what's on that like what I can't see right like I have a fear of that and I It told me what it's called. I can't remember now, but there is actual fear that that of course chat to be she told me that I made perfect sense and that speaker-1: Of course you did. speaker-2: Anyways, we digress. But, but you know, the point being that as we learned as we learned, like through the hard way, a lot of it, right? By just making mistakes and muttering, muttering our way through it? as we like learned from, like I said, Jodi and Kim, and as we learned from other like billing provider, you know, and then now that now where we're at now, I can also say this because I no longer own an AVA company and we have way past now the extension, like the timeframe that they could come back and ask for money back now, I will say even after we closed. There were like years. speaker-1: Tell the people this. Now they're gonna, Optum is gonna be listening to this and they're gonna- speaker-2: It's like six years now. You can't come back and get me. I did nothing wrong for you to come back and get me for. Anyways, ⁓ yeah, so I have to say like that fear is no longer over my head. And so it's easy for me to say, ⁓ if I were to have an auto right now, I think I would be able to like pause and grounded, whatever bullshit. I still would be scared. I would still be nervous. I would be still like, what does this mean for me? However, I do think that it... it's not quite so unknown now. And it's not as scary because I also know what my rights are. So that's what like, I would love to take the conversation today too. So those of you who are listening, not only like, I want this to be like, let's hold space for everybody who has this anxiety and let's talk, we can talk as much as we want to about it. And like, where are some like, not that we can go into all the ins and outs in like ⁓ our podcasts on all the things, but what are some, you know, misconceptions or what is, you know, cause like for example, ⁓ I do think it's important to pause because, for example, if you do act too quickly and act through your anxiety and you just start doing, then the chances are you will make mistakes and you will send things that you shouldn't be sending. speaker-0: I'm with you April, the anxiety came from, I don't know what this is, but what is this experience of an audit going to be? Like, I worked in residential. I knew what residential was. We had to do either a year or every three years, someone from the state come in and see the house, audit all the documents, all of that. But. It wasn't my company right that I was working for the company and so we had the things already set up and they were running and so I just needed to make sure that since I was the supervisor of the home to oversee all of that and make sure that we had all the things in the in the right places per the company request. Right. So because there is a delineation of information that was expected from the state. to the company down to me, I felt comfortable and prepared for this ⁓ person from the state coming in and essentially doing a residential audit, right? Now there was still anxiety connected to it, of course, but it wasn't as high as an anxiety that I had with that certified letter. And there's a couple of things, right? It's all on me. I'm the owner, I'm the BCBA. So there's more at risk, right? ⁓ But also the... There's a lot of ⁓ the information that is needed for an audit is not as clear in the mental like in the behavioral health insurance realm as it is for a residential care facility. ⁓ So there's it seems for me, from my standpoint currently that there's a lot of unknowns. There's a lot of I don't know what the right answer is. Like, there's these. big contracts and report that you have to read and know for each payer, but each payer is different and yada yada yada. And like, sometimes you don't even know all the details from that. Right. So, and then there could be things outside of that that like impact this audit that you have no idea about. So, ⁓ so that's kind of that really, April, as you touched on is ⁓ the unknowns. What is it that you're really expected to have in place? for these ⁓ audit requests and then hearing stories of 5,000, multiple million. And the spotlight is on the ABA community right now. So then that adds another layer of anxiety and worry, right? Because it's coming, we all know signing up for this, that that's a possibility that you have to be prepared for it. But what does prepared look like? speaker-1: Yeah, it's not a matter of ⁓ if it's a matter of when and and for anybody that builds TriCare I believe they're getting audited every year now and a BCBA reviews the notes so it is it is much stricter so like something that I would recommend everybody look up and is like Go recruitment audits and then your state ⁓ and see how far back insurance companies can look. like this is again, this is my perspective. You guys can take it or leave it, but a lot of times, especially with the audit component, this is your enemy. ⁓ This is not your friend. This is not a, like this is, this is, this is not a fair playing field. Anything that they can find that says they don't have to pay. even if it's ridiculous, that's on the list, right? This is in the rule book. So we had a recruitment audit request from one funder and we sent them the session notes and the treatment plans. And ⁓ they came back and said, we owed money and we also committed fraud. so their rationale for fraud, their rationale for fraud was that they Googled the bell times in our area and they... speaker-2: used the exact school. speaker-1: Yes. Yeah. And, and that they know that there's no way that we saw this child because they would have been in school at the time. Now, had they read the treatment plan that we got approved by them, that was authorized by them, and that we also sent in the audit, they would have seen that we were pulling this child out of school because in Virginia, that you are allowed to do that. And so that's, that's what we did. We, we saw them at home during the day. And so then, you know, we had to prove this And and then they came back and said, okay fine But this is this is where you're at. Like this is like how this is gonna be this is the game you're playing So knowing your rights super important. We had one funder that was asking to look at session notes from three years so ⁓ three years in the past and in Virginia they can only look back two years unless they ⁓ Have some ⁓ reason right? So if they've found if they've caught you in fraud then they can look back further But if they're just asking for session first request first request, they're not allowed to do that. Okay, so but don't assume these ⁓ This audit is gonna be a fair game and everybody's gonna do only what they're supposed to and no, that's not my that's not my opinion so at the end when we were getting recoupment eyes, I just I I didn't send anything. The first thing I would send is our letter from our attorney saying that we will send all the necessary ⁓ information for these dates and that's it. And so they saw the attorney's letterhead and in my opinion, they treated us with a little bit more respect than when we did those first few audits and we just sent in. ⁓ I have to assume that they do some kind of cost benefit analysis where they're like, okay, this person has an attorney. We're going to have the, our attorney involved. There's going to be a lot of back and forth. That's going to cost a lot of money. So let's just go down the street and find another sucker and take their money. You know what I mean? And that's just, that's just how I think they do it. So like you should not pay them for anything that you did correctly. And the other thing I will say, On this is even if your session notes are maybe you give them a score. I don't know 80 % Maybe give them a B, right? Just because one thing is missing from it doesn't necessarily Does it necessarily mean they get to take all their money back? Right? Like so again, that's something that I would highly recommend that you talk to an attorney about right is like Okay, they sent this letter and said we were missing. I don't know Right? Maybe the parent signature. We didn't capture the parent signature. We have the time in time out. We have the GPS location. We have the signatures of the BCBA and the tech, but we didn't get the parent signature. In many cases, you may be able to fight for keeping that money and not losing it. Right? So just because they say you owe money doesn't mean you actually owe money. Right? And so that's something now. It's going to get expensive. It's going to get time consuming. But again, my opinion is talk to an attorney, Kim Mack Rosenberg. Amazing. No one else I would trust with ⁓ on insurance audits and ⁓ reach out to her and get some advice and don't pay anything more than you should. speaker-2: Yeah, I think that's super important to so first of all to Azure spinning out inspiring out of control and thinking all the worst case scenarios. Don't act on it. Do not act on it. ⁓ Wait, seriously, wait and wait a day or two if you need to get into you're in a spot where because we know like when our nervous system is all activated, ⁓ we're not going to make clear decisions and we are more likely to make mistakes even if we did try to gather all of the stuff now to be well, they give you a timeframe of when they want it back. And that's another thing. If their time frame is too short, too quick, ⁓ know, Kim and Jodie taught us that you could reach out to them and ask for an extension. And you explain the hardship that that's giving on your company, right, to be able to gather this data and provide what, because right now your number one priority is providing services for the individuals. you know, especially in a small thing, a small career, the BCBA wearing all the hats, and it might mean you have to cancel Now, I know it's not quite as big like with practice management software, I do feel like that piece is a little bit easier for us. Our first few audits were like paper pen ⁓ binders, right? And we're like going through binders, looking for data sheets and we're photocopying things and we had like stacks of paper that we were they were asking us to fax and they like, we can't fax as much. Can all of those like moving pieces. So I think it's, I think I could be wrong, but have you heard of people having to send in like paper versions and stuff anymore? speaker-1: I mean you have to like I don't know if you export it as a like a PDF and yeah and then the problem is is that you may ⁓ you may have to fax it right now speaker-2: Yeah, so guess depending on how they're wanting the information, it could be, it could very well be a timely thing, right? It's not just as easy as like, ⁓ okay, you want these dates, because then you're also going to want to review to know what you're sending. Like Stephen said, even if there are mistakes, you want to be able to note it on your end. And so I already have like, a justification behind it or some kind of other, you know, information to follow up with it. And be like, ⁓ I didn't get the signature from this client or from, you know, on this session. But hey, guess what? there was a, supervisor was out, the BCBA was out at that session and they got the parent's signature. And so you could like provide whatever, you know, provide that evidence. main thing though, I think is really to pause and to know that there is no rush. Like you don't have to, so even if it's a quick turnaround time, your first communication, whether it's for an attorney, I mean, or from you, I mean, these first few, it may be really good to do, to use an attorney. We learned a lot from our attorneys and they gave us the wording to use and we started doing these ⁓ communications on our own, but we always knew that they were there to support us if we needed their like, just let us know. We'll send you over a letterhead if you need to escalate it. so that's the first thing is like sit with it, pause, don't send anything, don't do anything, don't panic. Cause that's the thing, that's my number one, I mean you can panic, but don't panic send, okay? That's my number one advice because I think a lot of times we think, okay, Especially if you're like a rule follower and you're you have all this fear. It's so easy to be like, okay, they told me to do these things. Let's do it. Because like Stephen said, that helps slow down the process to say, okay, what's my time? Can they even be asking for these dates? Right. ⁓ And then we'll talk more. like, and then what to send, right? Because you don't want to over send either, because that could trigger some other issues. So yeah, so have an attorney on on retainer or at least have a relationship or reach out ahead of time with Kim or someone there. think there are a few more ABA law people out there now. then even, you know, I'm thinking, what if you put like a visual for yourself, like ⁓ open in a case of emergency? You know, I never did that, but I'm just thinking that on the fly right now. Yeah, yeah. A little flask in your desk. No, I don't condone drinking, but. ⁓ speaker-1: some pot in there. speaker-2: the like an open case of emergency file to like remind yourself like, okay, here are the steps first, second, even just like the top three things, like just to get you centered, just to get you grounded, just to remind you, hey, it's okay, you don't have to act on this right now. speaker-1: April and I are so honored to have Margin Keepers sponsor this podcast. speaker-2: Running an ABA business comes with its share of challenges. Managing clients, staff, insurance, the list goes on. speaker-1: One thing you shouldn't add to your stress, bookkeeping. That's where Margin Keepers comes in. speaker-2: They're specialists in ABA businesses, which means they understand exactly what we need. speaker-1: With Merchant Keepers handling your finances, you can focus on what really matters, your clients and your practices growth. speaker-2: They're more than just bookkeepers, they're lifesavers in the financial world of ABA. speaker-1: So for peace of mind and expert financial management. speaker-2: Turn to margin keepers. It's a decision that will lift the weight off of your shoulders. ⁓ speaker-1: Check out MarginKeepers at www.marginkeepers.com and see how they can help your business thrive. I mean, something that could be helpful is doing internal audits, right? And so actually doing this ahead of time. So grab a random five sessions from your different staff and just see what they look like, right? And what would you rate them, right? Let's forget about... speaker-2: Different clients, speaker-1: What Optum or Atna or TriCare would ⁓ rate them? What would you rate them? Right? Or is there any components missing? That's a big thing. Auditors will look for that. Even if they don't personally require a certain item be filled out, if it's missing in there, you will get dinged for that. So is anything missing? Are you seeing a trend? Are we seeing copy and paste of notes? speaker-2: in an NA for not a pickable. All have to have something in them. speaker-1: So that would be my recommendation, right? Is get, do this often. And then, you know, sorry, Kim, but I hope hundreds of people call you ⁓ after this podcast, but like talk to Kim. Like I just have send her an email, call her, schedule an appointment, totally worth it to get that relationship so that when things happen, you have that person that can help you. Maybe she can recommend someone else that can support you in your state, but that would be my first communication is let's form that relationship so you have those experts in place so you're not alone. And then just know that this is a marathon, it's not a sprint. So you could panic send these, right? You could say, I've got the certified letter today, I am going to send them and I'm gonna do it in this hour. I'm gonna like literally leave the post office, drive to my office. It takes me five minutes. and I'm gonna export everything and I'm gonna send it right now and it's gonna be there. You're gonna be waiting six months. So this feeling of like, ⁓ they're coming again. Like this doesn't end. It's going to be there for a long time. So that's just something that you need to be aware of. This doesn't end quick, even if you send them quickly. And yeah, definitely don't panic Sam. But if you do, just know that this doesn't fix anything. It may make it worse. ⁓ only send what you need to. So something I did stupidly on our first audit was they asked for certain sessions and most of them were direct service. Tell you the code. speaker-2: So like they'll tell you like the CPT code and the client and the date of service. speaker-1: And so, you know, one of the things that our team asked, because I had never been through an audit, was, okay, well, we did parent training and supervision on some of these days. Should we also send those? And I was like, of course you should send those. Why wouldn't you send those? Yeah, yeah, anything. Yeah, let's send all of it, right? And that is not, don't do that. You only send what they're asking for. Another tip, you may want to send in the treatment plan ⁓ with the sessions. speaker-2: Like got like assessment Kim says to, she says, even if you're certain that they have your treatment plan already, you send them the treatment plan. Listen, we had ⁓ like one of our audits, or probably our last one that we had, we had multiple kids and I think it was like six kids. And we had multiple dates of service per each kid. And she had us attach the treatment plan to each date of service. ⁓ Because she said, you have to make this so that someone who has no idea what they're doing can look at this and not have to do any guesswork of what goes with what. so she had me take the treatment plan. And I wish I could probably go back and pull some of these up at a later time. And of course, not sharing a PHI, but like try to get some more pointers. And maybe we can do like a little workshop or something. ⁓ speaker-1: We are, we're gonna be doing a session of training. speaker-2: Yeah, that's true. I should probably pull that stuff up before a session training. ⁓ But it's so like, let's say they had they said, I can't even remember a specific feedback. But let's say they gave feedback of a concern on a session note of like the session notes that you play Candyland with the child, right? And they're like, this isn't like how was how was this ABA? Right. So then I went back and I found the maybe there was a turn taking goal. being able to take turns with a sibling without biting his brother or something like that, right? Or hair pulling or whatever. Maybe it was a behavior reduction goal. We all know you can use Candyland for a million different goals and use it medically in a medical necessity necessary way. ⁓ so then I highlighted that goal and the treatment plan. And then I had a crosswalk ⁓ saying, okay, here's your feedback for this data, here's the data service, here was your feedback, here's my justification, police, you know, a in treatment plan, ⁓ and this is why we use Candyland, blah, blah, blah, right? And have a master sheet and there's like have it all ⁓ organized. But yeah, that was the thing having a treatment plan. So even if you at minimum send in that current for that data service treatment plan, for that data service. Because you remember, it might not be the current treatment plan. It might be a past treatment plan that it corresponds with that session note. speaker-1: And it may not be the same person looking at every session too. So that's the other thing, right? speaker-2: So if you're like, okay, here's this. So you have to like treat every ⁓ session, every date of service and code for date of service as its own separate entity, right? Cause it could get split across multiple desks and people would be at that was something that I didn't understand. I expected this whole pack to go to one person. And so this is a great conversation because like I'm, as you can probably tell the way that we're like. ⁓ and this and this, like I said at the beginning, like this was not a planned, like we didn't have like a here are five things to know, but like it's just we're recalling from our memory and it is jogging some, some. speaker-1: You know, like Alicia was mentioning she's going through the OptiMod.it just prior conversation was Alicia and I going through the OptiMod.it. And so the other thing that I highly recommend is page numbers on all of these documents. And so it's not just page one, two, three, four, it's page one of 15, page two of 15, page three of 15. So that way they know that they have the whole file. and, and there is an issue and then something else that Kim and, hopefully they're okay with us shutting them out. ⁓ Kim and Jodi recommend is keep a copy of this file. Right? So don't just grab it all, then send it out and say, okay, I'm done. No, just like save a PDF of this, the exact files that you send to them. Because sometimes even though it, they claim it was submitted. ⁓ It may be lost and so you don't want to lose all of that work that you did So I would just store that as a file name it so you know where it is and then just keep it just in case Right because they'll that well, we only got 25 pages and you're like dude I sent you a thousand pages so, know so that you you have that information speaker-2: Another tidbit that I'm remembering is, ⁓ so you know how a lot of times, especially if we're doing in-home services, I'm not sure how often this happens in clinic, but in in-home services, we were very careful not to put the client's name or even the initials on the data sheets, especially if they were printed off, There again, this might not be, I'm gonna be off. speaker-1: It's old school stuff. Now you're talking about old school. speaker-2: Yes, it is. is but here's the thing I know I know 100 % fact that there are at least a handful of you listening right now who do not have a practice management software and they're doing this on their own whether it's paper pen or it's Excel spreadsheets or Google docs or whatever Because yes, because here's the thing if you do have like let's say you use client. Let's say okay Let's just say I'm not judging here. I really am not but I feel like calling you old-school might be judging you But if you are using paper, pen, or if you're like printing off like data sheets, even daily data, and you're keeping these as part of the file, and this is something that is adjacent to the session note that you need to send, you need to make sure that everything has the client's name on it. And so if it doesn't already, if it just has like a client number or a nickname, we did, our clinicians got really like fancy and creative there for a while. And we had like Donald Duck and ⁓ Elsa and we had like Disney characters were like the code name for our for our kids because the initials were like getting redundant because we had too many kids with the same initials. so you would need we you would need to supply a key for them to say, OK, 135 means Stephen Smith. You know, so here's the other thing that that just brought this up to me. And I there again, I think this is it's. If you do it within practice management software, it tracks changes, However, if you have an audit and there's, ⁓ we want the notes for January 5th for 97155 for Stephen Smith. And so you go to that and you're like, ⁓ crap, ⁓ that ⁓ session note is missing a piece of information. But it's like something minor that you know, ⁓ they forgot to put like, the year on it or they forgot to, I don't know, they said, but what about session notes or anything? speaker-1: Management that wouldn't happen anyway Yeah, I mean, but there could be components in the session, the narrative that are missing. speaker-2: What I'm saying is you can't change anything. Yeah, don't go back. if it's within your practice management software and it's going to track the change or whatever, it doesn't matter. Like we were told you cannot make any changes. You have to provide to them the original documentation that was made at the time of service. You cannot go back and change. speaker-1: Don't name Now there are ways that you can make changes after the fact, but like if you are like, oh crap, we have an audit and now these were from eight months ago and you're exporting them and you're realizing, oh wow, all of this stuff is missing or the entire, uh, the entire session narrative is, uh, an emoji con, right? that's a smiley face. Um, that this is not the time to go back and make these changes. Again, this is where. I have already talked to my attorney and then said, look, our session note isn't the greatest. What else should we be providing as evidence that we actually did what we said we did, right? We actually earned this money. So making those changes, very important that you talk to an attorney before you're just editing notes. That's not a good idea. that's- ⁓ speaker-2: So that's for those handful of you, especially that still have paper. speaker-1: But like, like shout out to office puzzles. They are our sponsor of the podcast, dude. It's $19 and 99 cents a month. just save yourself like the headache and the overwhelm and the anxiety. Like, ⁓ like when we were doing paper pen, a paper pen and we had recruitment audits, like people would spill coffee on their notes, right? They would, they would get all crumpled up or. They wouldn't fill out the whole note, right? Like these are not things that you wanna see when you do these audits. And that's why I would recommend everybody just at random, just pick 10 session notes over the last six months and see what they look like. Now at least you have a starting point and you know, okay, wow, we're failing. What do we do? Or- speaker-2: Even if you're like, I'm not doing paper pen. That's archaic. We- speaker-1: Happy spreadsheets! speaker-0: I would also add, having a practice management, there's still anxiety that is connected. We have a practice management. We take ⁓ data through a practice management system. because there's ambiguity about what is actually required and notes, who knows? So then it's like, OK, yeah, we do an internal audit, but it's an internal audit. good enough, right? Are we covering the same things or the things that would stand out for recruitment audit, right? So I think that's also kind of a component to like, you know, unpack in the future too. But, you know, like I shared earlier, I went to a state specific audit, prep training, and all of this is Very relevant to what was shared there as well. And like, you can do a done to note, but there's a specific way that you to do it. I don't even know if I'm to do that. And our practice management and those kinds of things. But, you know, it's still really not rocking up as far as those. Really specific details, you know. So, but it practice management all the way. So they'll a lot of today. But just to make sure they have But then make sure that you. speaker-2: I think that's a really good question too. Like, okay, sure. Okay. I'll pull 10, 10. I'll do my own internal audit. I'll pull 10 thing, 10 session notes and audit. What? Okay. I think they look fine. How do I know insurance is going to look fine? And I think that too, even so now it can be difficult to, get that information from the, the payer and And so, but some steps that you can take is you can look at your agreement, right? And you can say, okay, do they have anything specific? Some of them do. Some of them, well, mean, Optum, you go through the whole audit to get a network with Optum, right? So that's one that you typically, typically, nothing's a guarantee, no going into that what's expected. speaker-1: Yeah, but they don't do a really good job of session, right? So they're not going to be looking at the narrative and saying, well, this doesn't match the treatment plan, right? So that component of it, they're still not going to be checking. And that's where a lot of these recoument audits are coming from. It's the narrative itself that is the issue. You have the place of service. You got the time in, time out. You've got all the signatures. And so it's this, you know, we... reviewed these targets and they mastered these goals or whatever, right? I'm not a behavior analyst, obviously. And so it's that component of it that a lot of practices have issues with, right? And I totally agree. Like I looked at these, they look fine. But where I would come at this is the initial thing is, you know, understanding how to even do it in your system. How do I pull out session notes, right? How do I make addendums if I need to in my, like, so you know how to do these so that when you are in that panic, you can actually navigate these things. And then, you know, the last component is going to be the narrative. 100 % CASPS got a session note training. It's free. So everybody should be taking that at least every year. speaker-2: too. They have one for like a clinician. speaker-1: Now the only problem and our session no training will be exactly the same is that we can't guarantee that this is going to meet every insurance funder right and and it's constantly changing right so my recommendation even if you're not in network with TriCare you're not taking TriCare TriCare has a wonderful manual right and so using TriCare the TOM the TriCare operations manual They have specific things that they call for in a session. That's my go-to is using the TriCare operation menu and meeting their standard is going to be very helpful. The other option out there, if your practice management software has it and you can afford it, is having AI review these notes can be very helpful. ⁓ speaker-2: ⁓ and a shout out to Cilna because there and I can't gosh, it just actually came out today. if you want to because this will this will air a few weeks from now. So if you want to go back and look at the podcast with Jeff from Cilna on that came out on February 26th, ⁓ we talk about there's like some of the technology with the treatment plans. speaker-1: can review the treatment plan to make sure they meet the funders requirements, which is great. ⁓ speaker-2: And then so, but so something I just want to say that could be a little comforting, ⁓ is I remember several conversations that I had with Jodi in particular, and then Kim also more recently where they reminded that the first thing though is, there, there's a difference between fraud and shitty notes. And so The first thing, first things first, you have to, if you can provide that the session did happen, right? And so like, if you don't have a note for a session that they said that you built for, and then you go back through and you look through your records and you realize, yeah, I built for that session on January 5th with Suzy on, you know, from two to four, and we have no record of this, then you're kind of, you're going to be paying that back, right? For that two to four session with Suzy. ⁓ speaker-1: And you should, right? Like this is just, you absolutely. speaker-2: Maybe it was a mistake. And then of course, then that's going to trigger, okay, what do we need to improve with in our systems to make sure this doesn't happen again? speaker-1: And that's why I'm saying do your own internal audit. Like I said, just take 10 random and see where the bleeding is, right? Like just know where your mistakes are. speaker-2: well i'm not going to add a session of this not there speaker-1: Well, they can check like, okay, we were supposed to like my client got or my employee got paid for this session on this day. We can, you can take it as far. Yeah. Yeah. You can take it as far back as you want. Right. And so you can look at a remittance and say, I'm going to check from these remittance and see if I have them. Right. And walk your way back. So there are many things that you can do, right? In the units is something big too. speaker-2: Maybe look at the sky. So let me just really quickly finish that thought. So she said, you know, so you want to make sure that, so first of all, that the session happened and that it's not fraudulent or that you build it correctly, right? You didn't like use the wrong modifier. didn't like, I don't know, double billing. I'm not in the billing world anymore. Is double billing still an issue like for speaker-1: You can absolutely double bill. speaker-2: So anyway, so making sure that the session really did happen and then That's what I meant, right? Catching those things, like that you're billing for sessions that didn't happen, or you're multiply billing for the same session and all of that, right? So that aside, and then you look and you're like, wow, we did have these sessions did occur at the time and time out is accurate. Like these things are, however, yes, in the narrative, maybe the notes are cloned or appear to be cloned. They're too similar or, you know, or It's just not, we're not using the right wording here. Or maybe we're using, ⁓ you know, maybe we're realizing that this insurance company doesn't like, we had one that didn't like when we talked about pairing, but we didn't have a specific goal in the treatment plan for pairing. Little things like that, that you get to know. And so then that's, this gave me like, ⁓ like it gave me some. feeling of control and ownership over, this is something I could do, something about. And so it was like being able to even go back to the payer. Yeah, so this gave me some peace of mind and gave me some like feeling of ownership over it. That if you do realize, even if it's not in your own pre-audit, in your own internal audit, but it's like within a real audit and you realize that your session notes are lacking in places, own that. Like you can own that and you can say, yes, thank you for this opportunity. We do agree that X, Y, and Z, we can approve upon this. And now that we know what your standards are, because back when we came in network with your, like we asked for the standards and they were not given to us. But now that we're starting to understand what you're looking for in these notes, we will definitely put these in place for next time. these sessions did occur and is not fragile. And this is part of what they helped us to formulate during our first learning experience of how to word that. And they put it on. you know, within the attorney's letterhead moving forward. And then we did for this particular audit, we did have a follow-up audit, I don't remember a year later or something. And we were able to show that we made these changes and we've improved our systems now that we got the communication from them and we got checked off, right? speaker-1: Some people get put on a pre-audit check as well. So that's just something to be aware of where they won't approve the sessions until they audit the session notes. It's just something that does happen from time to time. Again, this just goes back to owning your own notes and like don't put your head in the sand and just say, I'm going to wait for that certified letter and catch me if you can. I know if it was me, like it's really hard to sleep at night knowing that this thing is coming. So. just this is a great opportunity, right? Is look at your own system, see where the flaws are, see what we can fix internally. And then, like you said, ⁓ April, just because your note is an F doesn't mean they get their money back. And so working with someone that's knowledgeable on this is something I would highly recommend before you give any payment. ⁓ And just know that these things are going to happen. over and over again. And ⁓ yeah, the baseline should be we don't commit fraud ⁓ so that they can't look back. But like just because you don't think you're committing fraud doesn't mean they're not going to say you're committing fraud. So it's just something to be aware of. the other thing, we did have some success with some of our audits where they told us what was wrong and we made steps to fix it. But then there were other audits, like the post audit meeting where it's like, what are you even talking about? Right? Like you're saying that we don't have rationale for these goals. And it's like, it's in our treatment plan. Right? Like what are, come on. ⁓ speaker-2: Each section can't be three pages long. Like that's why there's a sheet men play. speaker-1: Yeah, and so like it's some of these post audit meetings were very disappointing. And so just know that you may not get that. Like my experience with audits was you get to find out the problems so that you can correct it. speaker-2: You can switch the way you look at it. You can take some ownership and switch that perspective. speaker-1: But some of these post audit meetings were very disappointing for me because I want to know what I did wrong so I can fix it. Like that's my like that's what these should be about. speaker-2: We had some where they were saying that they were going to recoup a lot of money. We sent our files into them. We never heard back from them again. so eventually a couple of years later, we're like, well, I guess we're good. I guess they're not going to come after us for that money. Remember that? speaker-1: Yeah, I mean, I remember one where they said we owed $140,000. I remember that one. And then we sent in additional information and they said, my bad, don't worry about it. like that's just. And I remember, I remember now what it was. speaker-2: They're very like nonchalant. speaker-1: we had one audit where they said we did everything wrong. And then it turned out they were holding our like, and I don't remember the year, so I'm just using yours, but they were holding our 2013 note to a 2015 standard and saying, why didn't you have, well, dude, I don't have a time machine. So I can't know what your 2015 standard is in 2013. You're not allowed to do that. And so these are the things that they will try to do. So just be aware of that, right? If you have a standard, follow that standard and they can't come back and say, you know, well, you should have been following this. No, that's not fair. Right. And so that's something else that did happen. So it's just, you know, these are the games that you're going to have to play. so just know knowing this can be helpful. And I don't mean this to be a scary thing, but for me it was. And I don't know if I ever really got any better with it over time when When you could potentially have an audit where they're asking for hundreds of thousands of dollars back with no justification, ⁓ I don't know that it ever got easier for me. speaker-2: But I did feel like I had more control. Once we went through a few of these, we started to understand our rights. And we started to understand even some of the basics, just like the fraud versus a bad note. And really understanding those key components to it did help me. Maybe it didn't help me feel less scared because there was still, I think it did help me feel less scared. There was still the fear there. But it did decrease it because as I started to realize, hey, we do know our rights. We are able to communicate these. We are able to go back and forth. It's not a quick, all of a sudden someone's going to show up at my door with handcuffs or and say, you've committed fraud today or, you know, and, or I'm not going to have to shell out hundreds of thousands of dollars the next day. Like it did allow me that, that piece to be able to, to slow things down. speaker-1: And just one other thing if you do find that you do this audit and you're like Steven Why did you make me do this audit? I found a whole bunch of mistakes or I miss billed when I shouldn't I build when I shouldn't Self-report right? Yeah first talk to an attorney talk to Kim But I would highly recommend self reporting if you are within the timely payment doing a adjusted claim I like don't hide this stuff like just just come clean and figure it out. But there are ways to self-report where it doesn't necessarily mean you're gonna get audited. But if you're upfront about this stuff, it's going to go a whole lot better for you. speaker-2: you train your to you update your policies and procedures you train your team and then you continue to speaker-1: You found find out you double billed or you know, whatever it may be like now we found the problem Let's fix it talk to Kim self-report, right? Because if if you Here's something to know is most medicaid's have if you find fraud Right if an employee finds front they get a percentage of it So if you have some random person in your company audit your books and they find fraud ⁓ It's better to up to own up to it ⁓ Even if it's unintentional right unintentional doesn't ⁓ It's better to be upfront about it and self-report versus have one of your employees report you. speaker-2: That's the scary thing to think about. So I want to be respectful of Alicia's time today because I know she's small business ABA owner who's wearing all the hats and you guys all know what that's like. ⁓ So if you're listening to this ⁓ and you're like, okay, all right, well now I feel even more anxious or overwhelmed and I have my head spinning out, I don't know where to start, just reach out to us and we'll help you to at least kind of ⁓ figure out your first steps. ⁓ All right. Well, thank you so much, Alicia, for being vulnerable and for sharing your story and for showing up for this conversation today. speaker-0: Of my pleasure. Thanks for having me. It's been a good conversation. Of course, stuff's to grow on and continue, right? It's opening the windows. speaker-2: There you go. There you go. All right. Well, thank you all for listening and I hope you have a great rest of your day and we'll see you here next week. Thanks for joining us on ABA Business Leaders. ⁓ speaker-1: See ya. We provide mentorship, courses, handbooks, billing support, credentialing, HIPAA support, web design, and more. Everything you need to build an ethical and sustainable ABA product. speaker-2: You can find all of our resources at 3pi2.com speaker-1: Don't forget to subscribe and share this podcast with other ABA business owners. speaker-2: We'll see you next time and remember you don't have to build your practice alone.