MIAMI — Six behavioral therapists from a company with offices in Miami Lakes and Fort Lauderdale billed the state of Florida for “impossible” days of service that at times would have meant they worked for more than 24 hours in a day, state investigators concluded as part of a Medicaid fraud inquiry.

The therapists, who mostly work with low-income children with autism and other developmental disabilities, were terminated from Medicaid last month. The company that employed them, DRA Behavioral Health, could not be reached for comment after repeated calls to their offices. DRA was among four South Florida behavioral therapy companies sanctioned by the Agency for Health Care Administration in July for failing to pay fines, hiring unqualified therapists and failing to disclose required information to the state.

The companies are:

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• MGM Behavioral, which agreed to repay the state more than $1 million on grounds it had used unqualified therapists. Sai Rivero, a manager at MGM’s Miami Lakes location, said the company had been using therapists trained in other countries, including Cuba, and whose experience and college degrees were not recognized by the state.

• Harmony Mental Health and Behavioral Services, which was suspended from Medicaid for failing to pay a $2,500 fine and provide records of its employees. Harmony could not be reached for comment.

• Meli Medical Center, with an office in Hialeah Gardens, was suspended from Medicaid and fined $10,000 because the owner, Orlando Chillon, allegedly failed to disclose that his plumbing contractor’s license had been revoked by the state in 2007. Chillon’s attorney did not respond to repeated requests for comment.

AHCA officials noted in the announcement that, “It is critical that the agency ensure the health, safety and welfare of the children receiving this service.”

But while AHCA, the state agency that manages Medicaid in Florida, continues its probe into behavior analysis services paid for by Medicaid, schools and programs that provide the therapy to children say the agency is dragging out authorizations for therapy and approvals of new therapists, effectively preventing children from getting therapy for months while reducing the costs to the state.

Delays ‘inexcusable’

The Florida Association for Behavior Analysis, a statewide nonprofit that promotes the therapy — which is designed to correct behavioral issues in children with developmental disabilities — said the delays are hurting kids.

“These delays are inexcusable and are causing heartache for so many children and families who desperately need the services provided by qualified behavior analysts,” Nikki Dickens, president of FABA, said in a written statement. “Our state government simply cannot sit back while these vulnerable children suffer as a result of an ineffective and inefficient bureaucratic system.”

In May, AHCA imposed a moratorium on enrollment of new behavior analysis providers in Miami-Dade and Broward counties, alleging rampant fraud that included therapists falsifying credentials and billing for more hours than there are in a day. The sanctions announced recently are part of that investigation.

But some Miami-Dade providers say AHCA used wrong or outdated information as a reason to suspend their therapists from Medicaid and then forced the provider to repay thousands of dollars.

Lissa Torres, founder of Carpe Diem Academy, a school that serves children with mild to severe disabilities in Miami-Dade and Monroe counties, said she paid AHCA $16,000 in May to settle allegations that three of the school’s therapists had fraudulently billed Medicaid.

About four weeks after Torres paid AHCA the $16,000, she said, the agency sent her its investigative report.

“All of it, except for $511, was a mistake on their part,” she said, “and I have the proof.”

Torres said AHCA based its findings on a self-audit of Carpe Diem’s staff from December, even though that information was out of date when the state looked at it. The state incorrectly concluded that one therapist was falsely billing for services — the therapist had departed the company but then returned — and the other supposedly didn’t have authorization to bill Medicaid, though it had been granted, Torres said.

When she tried to point out the error to AHCA, Torres said they told her the case had already been “resolved” and they refused to discuss it.

She said AHCA then took another action, suspending 10 of the school’s therapists in July — about half of Carpe Diem’s staff — alleging that they were not properly credentialed to provide behavior analysis, though the state had previously authorized the therapists for Medicaid.

Mallory McManus, AHCA press secretary, said in a written statement that Carpe Diem was given “due process.”

“The provider agreed to the overpayment, rather than the agency conducting our own audit,” McManus said. “In fact, this provider on at least one occasion billed BA (behavioral analysis) services for more than 24 hours in a single day, something that is clearly impossible.”

Credentials questioned

Torres said she resubmitted to AHCA all of the required documents for each of the suspended therapists showing they were properly credentialed, but has gotten nowhere. For now, Torres said, she’s paying those therapists out of her own pocket for their services in June while she waits for AHCA to reauthorize them.

“I’ve had to max out my credit card,” she said, “and I’m currently looking to take out a home equity loan. I promised parents and families a service. I can’t let them down.”

Torres said Carpe Diem serves about 150 families through campuses in Kendall, Little Havana and Key Largo, and she’s concerned that her students with developmental disabilities will lose the progress they’ve made through behavior analysis therapy, the only evidence-based treatment for autism endorsed by the federal Centers for Medicare and Medicaid Services, the U.S. Surgeon General, the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the health departments of several other states.

“We service severe kids, and some of these therapists have been working with these kids for over a year,” she said. “What about continuity of care? Legally, these children have a right to this care.”

If she can no longer afford to pay her suspended therapists, Torres said she will have to create a waiting list for children who need behavior analysis using the therapists who can still bill under Medicaid — a step other South Florida providers have already taken.

Lori Sugar, a certified behavior analyst with Broward Children’s Center, a nonprofit group in Pompano Beach, said delays in state authorization for new therapists have caused her organization to turn away families with Medicaid whose children need therapy.

“It’s really bad. Everything is pretty much at a standstill right now,” Sugar said. “I’m sitting here with a longer and longer waiting list, and I can’t hire new behavior techs unless they come to me with a good Medicaid provider ID.”

The legal right for Florida children with Medicaid to receive behavioral analysis was established by U.S. District Judge Joan Lenard in Miami who ordered AHCA to begin paying for the service in a March 2012 court ruling after the agency argued that the therapy was experimental and that requiring the state to pay for it would cause spending to explode.

The agency was correct about the spending growth. In 2012, AHCA spent $3.1 million on behavior analysis services for children with Medicaid. By 2017, spending skyrocketed to $356 million. This year, AHCA has reported spending $131.9 million for behavior analysis from April through July 11.

AHCA has urged parents of children with Medicaid to contact the agency if they are having difficulty getting behavioral analysis services as the state continues to add new providers to meet demand.

AHCA officials said the company contracted by the state to review and authorize requests for behavior analysis services has approved 13,687 requests for Medicaid to cover the services since May 1 — authorizing services for 11,564 children. AHCA also has added 253 new behavior analysis professionals to its roll of providers in the Medicaid program in about two months, from mid-May to mid-July.

But the agency also has set goals for “cost/value containment” to manage behavioral health spending, according to emails and letters between AHCA officials and executives of Beacon Health Options, a company contracted in January 2016 to review and authorize the services. AHCA canceled the company’s contract this year, in part for approving too many service requests.

AHCA Secretary Justin Senior canceled Beacon’s contract in March in part because the company had approved 100 percent of the services requested in 2017, which Senior said “strains credulity.”

In the emails and letters, Beacon executives placed some of the blame for the company’s high rate of approvals on AHCA for mandating “unrealistic authorization turnaround times” of three days to greenlight services. In a March 6 letter to AHCA, Brian Wheelan, a Beacon executive, said three days wasn’t enough time to properly vet service requests. He said other states allow 10 to 14 days for initial authorization.

Wheelan also noted that Beacon had been awarded a contract to serve a projected 5,600 eligible children, with a spending target of $10 million per month — when the state knew that there were about 10,000 patients on Medicaid waiting lists.

© 2018 The Miami Herald
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