TAMPA, Fla. — Publix and a health care firm that provides therapy for children with autism are locked in a multimillion-dollar legal battle over unpaid medical bills for children of Publix workers.
ABA Cares sued the Florida-based grocer on Aug. 25 on behalf of 10 Publix workers whose children have been diagnosed with autism spectrum disorder. Its lawsuit, filed in Broward County, states that Publix has refused to pay medical bills since October despite pre-authorizing therapy sessions through its self-funded health insurance plan.
Publix countersued the health provider in federal court, accusing it of a scheme to defraud its health plan out of $15 million. Instead of collecting patients’ portion of the cost of therapy, the lawsuit states, it did not charge them and compensated by overbilling Publix.
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The children, including one from Pasco County, are not named in the lawsuits. They range in age between 4 and 17.
Autism spectrum disorder affects how people see and interact with others and can lead to aggression, the urge to run away and self-harm. There is no cure but a therapy called applied behavior analysis, which teaches coping skills, is one accepted standard of care.
ABA Cares, which operates as ABA Centers of Florida in the state, has continued to treat children insured through Publix while trying to negotiate with the company, said CEO Jason Barker. It provides autism therapy in 12 states and Puerto Rico.
Meanwhile, Publix has continued to pre-authorize autism therapy with ABA Cares as recently as last month, Barker said. The situation has created uncertainty and anxiety for families.
“Their biggest worry is that they lose services and what will happen to their child?” Barker said.
Publix officials said it would not be appropriate to comment on pending litigation but referred a Tampa Bay Times reporter to its countersuit, which it filed one day after it was sued.
Federal Judge Kathryn Kimball Mizelle dismissed it saying Publix’s 27-page complaint was an impermissible “shotgun pleading” largely made up of “irrelevant factual allegations and legal conclusions.”
The grocery chain responded earlier this month filing a 221-page amended complaint that includes exhibits of what it described as fraudulent billing.
It accuses ABA Cares of having submitted duplicate requests for payment for the same therapy session and billing for services that never occurred or are not covered by Publix’s health plan.
Since ABA Cares is an out-of-network provider, Publix workers would be responsible for 40% of the cost of treatment until they reach their out-of-pocket maximum. But the therapy provider did not collect any payments from some parents despite its billing conveying the opposite, the lawsuit states.
One example lists an insured member for whom Publix’s health plan received 180 individual claims in 2023 totaling $800,000.
Billing submitted by ABA Cares made it appear that the member had met their $1,000 deductible and $7,000 maximum out-of-pocket payment, the lawsuit states. But the member or their parent indicated to Publix they had not paid “even $1 of copay or coinsurance.”
Publix paid at least $5.8 million to ABA Cares over a two-year period through October 2024 before the “fraudulent billing was detected,” its lawsuit states.
When asked about the claims made by Publix, an ABA Cares spokesperson provided the following statement:
“Our first priority is the well-being of the children and families who rely on our services. Although we believe the claims lack merit and that our operations fully comply with all applicable laws, we are committed to working toward a constructive resolution with Publix that is in the best interest of the children we serve and ABA Centers declines to make any additional public statements at this time.”
Self-funded insurance plans like Publix’s have become more popular since the passage of the Affordable Care Act in 2010. It allows companies to avoid paying a fixed premium to a health insurance company but means assuming the risk of paying all of the employer’s share of medical expenses for enrolled workers and their dependents.
Around 1 in 31 U.S. children had been diagnosed with autism by the time they were 8, a 2022 study by the Centers for Disease Control and Prevention found. It is three times more common among boys than girls.
Symptoms like difficulty communicating typically appear before the age of 3 and vary from mild to severe.
Applied behavior analysis, the therapy provided by ABA Centers, is regarded as an evidence-based best practice by the U.S. Surgeon General and by the American Psychological Association.
The American Academy of Pediatrics recommends children with autism spectrum disorder receive early evidence-based interventions such as applied behavior analysis. Florida lawmakers passed a bill in 2008 mandating that health insurance companies include the therapy and other autism treatment in their coverage.
It can be expensive since it requires intensive one-on-one time with children. It’s not unusual for therapists to accompany children outside of the home to work with them on their behavior at venues like a park or the cinema or wherever they typically exhibit negative behavior.
A board-certified ABA therapist can cost $120 per hour, a 2023 report in Autism Parenting Magazine found.
ABA Cares is a member of The Council of Autism Service Providers, a nonprofit trade organization that represents about 430 therapy providers.
CEO Lorri Unumb, whose son was diagnosed with autism before he was 2, said insurance companies often balk at therapy claims because it requires intense repetition with repeated trials to get children the skills they need to function.
“There are still growing pains among health insurance providers in understanding (applied behavior analysis) and knowing when claims are legitimate or are not,” she said. “We see a lot of disputes between payers and providers.”
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