Documentation and Auditing

Practical Safeguards for Clinical Success

Original Air Date: January 11, 2021 (as part of the CASP 2021 UnCONVENTIONal Conference)

CEU offered: 1.0 Ethics CEU

Short Title:  Documentation and Auditing

Webinar Duration: 1 hour

CE Instructors:

  • Rebecca Womack, BCBA


Abstract: 

Organizations that provide applied behavior analytic (ABA) services to people with autism spectrum disorder (ASD) have an ethical, legal, and contractual obligation to document their work. It is imperative that the processes for equipping behavior analysts with the tools to produce high-quality session notes also enables them to discuss the medically necessary treatment provided. Organizations must have a clear understanding of what information is required by each funding source, and how to capture the elements of treatment provided that pertain to the billed CPT® code. They must also be able to evaluate their session notes on a regular basis to ascertain the quality of documentation in order to mitigate risks in the event of an external audit. By using carefully crafted auditing tools and systematic auditing processes, organizations can efficiently evaluate their session notes. Statistical sampling enables organizations to make determinations about their auditing results supported by arithmetic confidence levels. This allows organizations to then strategically plan for how to improve their documentation as needed. This session will discuss the essential elements of documenting medically necessary treatment and recommend systems and tools for effective auditing processes. 

Instructor(s)

MS, BCBA, LBA Rebecca Womack

Rebecca several years of experience rendering services via telehealth as well as researched this topic when advocating on behalf of providers and military families in DC regarding the TRICARE ABA benefit.
 Rebecca has been privileged to serve adults and children using ABA in a variety of capacities. From facility-based care, to working in group homes, daycare centers, schools, and family homes, her experience includes implementing evidence-based therapy across multiple settings. As part of this, she has traveled across the United States and overseas to provide consultation for families with children and adults who have autism. Rebecca currently serves as the Director of Clinical Compliance for Blue Sprig Pediatrics, Inc. There she works collaboratively with a team of interdisciplinary professionals to create quality assurance policies and ensure that related processes are ethically and contractually aligned with health plan standards.