Vermont agency narrows ABA telehealth and bars concurrent billing; providers warn of lost revenue and access

Summary

Vermont Medicaid officials told a committee that new rules effective Jan. 1 bar concurrent billing of ABA codes 97153 and 97155 and restrict telehealth to three codes to reduce audit risk; providers say the change could cut provider income, disrupt services for 154 Medicaid members and force some clinics to close.

Vermont Medicaid officials described policy changes taking effect Jan. 1 that stop concurrent billing for two common ABA codes and narrow telehealth delivery, saying the moves respond to federal audit risk and coding vulnerabilities.

Grace Johnson, a policy analyst with Medicaid policy at AHS, summarized the benefit: “Vermont Medicaid covers applied behavior analysis, which is ABA services for kids with autism.” Agency presenters said a lack of a written concurrent-billing policy left the program vulnerable to Office of Inspector General review and possible recoupments; they cited a Wisconsin OIG audit that resulted in an $18,500,000 overpayment recoupment as a motivating example.

Agency staff told legislators they would no longer allow concurrent billing for codes 97155 (adaptive behavior treatment with protocol modification administered by a qualified health professional) and 97153 (adaptive behavior treatment by protocol administered by a technician), and that billing should reflect the child’s face-to-face service time rather than two providers billing for the same hour. The agency also said it had narrowed telehealth to three ABA codes, placing…

Vermont agency narrows ABA telehealth and bars concurrent billing; providers warn of lost revenue and access

Summary

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