Combating Medicaid Frad And Abuse - Pewtrusts
Health Care Challengesin the StatesThis issue brief is partof a series that explorespromising state effortsto manage health carecosts across a range ofspending areas.ISSUE BRIEFCombating Medicaid Fraud and AbuseFraud and abuse in Medicaid threatenAmericans’ health and well-being bydraining funds needed for legitimatecare and potentially subjecting patientsto unnecessary or ineffective tests andtreatments.The toll on state and federalbudgets is substantial. In 2012, anestimated 19 billion—or 7 percent—offederal Medicaid funds was absorbedby improper payments, which includefraud and abuse as well as unintentionalmistakes such as paperwork errors.1Improper payments totaled an estimated 11 billion—or 9 percent—from states’Medicaid budgets in 2010, the most recentyear for which data are available.2WWW.PEWSTATES.ORG/HEALTHCARESPENDING Addressing these problems has becomemore urgent as the program expandsto serve more people. In part becauseof unemployment and other financialhardships caused by the Great Recession,states’ Medicaid enrollments grew to53 million in June 2011, up from 34million a decade earlier. And many statesare preparing to extend coverage withthe implementation of the AffordableCare Act in 2014.3Use our database to learn abouthundreds of state strategies toreduce fraud and abuse.www.pewstates.org/Medicaid-fraudMARCH 2013
COMBATING MEDICAID FRAUD AND ABUSEPolicymakers are battling Medicaid fraudand abuse with an array of approaches,including efforts to identify providers whoare more likely to commit misconduct,strengthen procedures for claim review,and recover improper payments moreefficiently. To help lawmakers learn fromone another, researchers with the StateHealth Care Spending Project, a jointinitiative of The Pew Charitable Trusts andthe John D. and Catherine T. MacArthurFoundation, combed through federal datato gather hundreds of standout practicesidentified by the Centers for Medicare& Medicaid Services, or CMS, and stateagencies. The results are organized in aneasy-to-use online database accessible atwww.pewstates.org/Medicaid-fraud. Thisbrief highlights their findings.Striking a BalanceStates’ health care costs continueto grow. Medicaid spending by statesalone—excluding federal matchingdollars—grew by 315 percent from 1987to 2011 after adjusting for inflation.4These expenses consumed an estimated20 percent of state general funds infiscal year 2012.5 One bright spot,however, was that Medicaid spending perindividual grew more slowly, on average,than did private insurance premiumsfrom 2000 to 2009. This trend suggeststhat much of Medicaid’s spending growthresulted from its enrollment gains.ABOUT OUR ANALYSISThe federal Centers for Medicare& Medicaid Services, or CMS,conducts periodic reviews of states’efforts to maintain the integrityof their Medicaid programs andguard against accidental andintentional errors, including fraudand abuse. The agency identifiespractices it finds noteworthyand invites states to submit theirmore effective approaches. Thisinformation is used to create areport for each state’s review i andan annual summary.ii We examined85 CMS reports available online asof February 2013 to compile andcatalogue the findings. The CMSreviews, conducted from 2007 to2012, contain information fromall 50 states and the District ofColumbia.Combating fraud and abuse is essentialto the sound fiscal management ofMedicaid, but states also shouldconsider potential effects whendeveloping and implementingstrategies to curb these problems. Anumber of state officials have stressedthe importance of striking the rightbalance between eliminating improperpayments and avoiding burdens thatcould discourage honest providers fromaccepting Medicaid-insured patients.“You could eliminate a lot of fraudby operating Medicaid like a policestate. But by treating providers likethey are potential criminals, there’sNOTE: Some states underwent more than one reviewduring that period.WWW.PEWSTATES.ORG/HEALTHCARESPENDING2
COMBATING MEDICAID FRAUD AND ABUSEno way they’re going to participate inthe Medicaid program,” observes MattSalo, executive director of the NationalAssociation of Medicaid Directors.6“pay and chase.” Drawing on the reviewsof states’ practices by the CMS, Pewcreated the Medicaid Anti-Fraud andAbuse Practices database, which organizesstates’ approaches by those three categoriesas well as a fourth that cuts acrosscategories, then further breaks them into13 subcategories.Strategies to Combat Fraudand AbuseFraud and abuse can be committed byboth Medicaid providers and patients.But in the project’s review of federaldata, researchers found that the vastmajority of states’ strategies are focusedon providers.The amounts saved or recovered throughthese practices can vary widely. But asthe examples that follow show, effectiveaction can contribute to the broadergoal of preserving Medicaid funds forgenuine health care needs.Generally speaking, states have threeopportunities to reduce fraud and abuseamong providers: (1) screening thembefore and after they are accepted intothe program; (2) reviewing claims beforethey are paid; and (3) reviewing claimsafter they are paid and recovering anyimproper payments, a process known asProvider ScreeningA state’s first priority must be tomaintain a pool of Medicaid providerswho follow the rules. To perform thistask well, states must vet prospectiveproviders diligently and monitorMEASURING MEDICAID’S IMPROPER PAYMENTSThe Improper Payments Information Act of 2002 led to the creation of a nationalaudit, the Medicaid Payment Error Rate Measurement, or PERM, which estimates thepercentage of payments that either should not have been made or were made forthe wrong amount—everything from 25-cent coding mistakes to fraudulent claimsworth millions of dollars.The most recent PERM estimates, as of November 2012, showed a national error rateof 7.1 percent.i Individual states’ performance typically varies.iiSome experts, including the National Association of Medicaid Directors, questionthe accuracy of the measurement, warning that “error rates in some states may bemisleading or G3
COMBATING MEDICAID FRAUD AND ABUSEthose already in the program withoutoverburdening them.Recent events in Louisiana illustratethe importance of vigorous screeningand monitoring. In January 2012, adentist was found guilty of two felonycounts of Medicaid fraud. Barred fromparticipating in Medicaid in 1992,he worked with another dentist inShreveport from 2005 to 2007 andused the other provider’s identificationnumber to submit false claims.13Some states require that all providers,including those used by managed careorganizations,7 undergo a centralizedenrollment screening process and becross-referenced against exclusion listsfrom the federal government, otherstates, and sister agencies. Kentucky, forexample, uses centralized enrollment toensure that health care providers havenot been sanctioned by the state’s medicallicensing board or excluded by Medicareor other states’ Medicaid programs.8Similarly, Wisconsin prohibits managedcare organizations from using providerswho have not enrolled through thestate.9 In Texas, the Health and HumanServices Commission performs criminalbackground checks on all managed careproviders.10 Most states also have periodicprovider screenings or reenrollmentprocedures, and some conduct randomaudits and on-site visits. “If you don’tlet bad providers in, they can’t stealfrom you,” says Glenn Prager, Arizona’sMedicaid inspector general.11FRAUD AND ABUSEDEFINEDFederal Medicaid regulationsdefine fraud as “an intentionaldeception or misrepresentationmade by a person with theknowledge that the deceptioncould result in some unauthorizedbenefit to himself or some otherperson.”Abuse is defined as “providerpractices that are inconsistentwith sound fiscal, business, ormedical practices, and result in anunnecessary cost to the Medicaidprogram, or in reimbursement forservices that are not medicallynecessary or that fail to meetprofessionally recognized standardsfor health care. It also includesrecipient practices that result inunnecessary cost to the Medicaidprogram.”The Affordable Care Act is strengtheningthese provisions. Under new CMSregulations, states are required toterminate Medicaid providers whoseMedicare billing privileges have beenrevoked by the federal government or whohave been terminated for cause by anotherstate. The agency has launched a Webbased application that is meant to facilitatestates’ efforts to share such information.12Source: National Archives and Records Administration,Code of Federal Regulations, Title 42: Public HealthPart 455—Program Integrity: Medicaid.WWW.PEWSTATES.ORG/HEALTHCARESPENDING4
COMBATING MEDICAID FRAUD AND ABUSEPrepayment Reviewstreat Medicaid recipients. A subsequentincrease in dental and orthodonticexpenditures seemed like progress.Spending on orthodontic care rose to 185 million in 2010—nearly doublewhat it was in 2008.15States’ next line of defense is tocarefully review claims before makingpayment, particularly for types ofproviders with track records of fraudand abuse. According to the CMS,suppliers of durable medical equipment(e.g., wheelchairs), home healthagencies, transportation providers,and personal care services are amongthe industries that have shown higherrates of misconduct.14 Claims arerun through a series of data checks,which flag those that appear to includeincorrect information, lack sufficientdocumentation, or run counter to thestate’s Medicaid rules.Subsequent investigations found thatseveral orthodontists were filing claimsfor children’s braces that were notmedically necessary and should not havebeen covered by Medicaid. Additionally,the private contractor that Texas hiredto process preauthorization applicationsgave approvals without appropriatemedical review. An orthodontist assistingin the state’s investigation estimatedthat at least 90 percent of the claims shereviewed would not have passed Texas’threshold of medical necessity.16Many of the data checks, called edits,detect obvious errors—for example,claims filed before birth or after death,or bills for hysterectomies performed onmen. Others ensure that providers arebilling for services that Medicaid covers.States also determine whether otherpayers, such as workers’ compensationor Medicare, are liable for the claim.States sometimes give providers a chanceto correct any errors or provide missingdata, and those who fail to do so receivepartial or no payment.In their CMS reviews, some stateshighlighted their rigorous priorauthorization practices. Nebraska, forexample, pointed to its prepaymentreview process as a success. To helpensure that services are medicallynecessary and meet all Medicaidrequirements before payment, theprogram integrity office in the state’sDepartment of Health and HumanServices frequently requests providermedical records, which are analyzed bystaff and medical consultants.17A case in Texas underscores the challengeof keeping up with ever-changing fraudand abuse schemes. Over the past decade,the state has tried to expand dental carefor needy children. In 2007, for example,it approved a 50 percent rate increasefor dentists to prompt more of them toNew York requires certain providersto prove that patients were actually attheir offices by mandating that patientsswipe their benefit cards on every visit.Additionally, select providers (e.g., aWWW.PEWSTATES.ORG/HEALTHCARESPENDING5
COMBATING MEDICAID FRAUD AND ABUSEphysician ordering a prescription) mustpost orders to the state’s electronicclaims system before another provider(e.g., a pharmacy) can process andbill the transaction.18 These programsgenerated a combined cost savings of 683 million from 2008 to 2011.19Post-Payment Claims Review andRecovery: Pay and ChaseEven after providers are paid, stateofficials can analyze claims in search ofaberrant trends or billing patterns anduse their findings to pursue sanctions,audits, or investigations. Florida, forinstance, sends Explanation of MedicalBenefits forms on a quarterly basis to allpatients for whom providers have billedservices and asks recipients to returnany they believe to be inaccurate. Infiscal year 2008, this practice identified22 cases of overpayment and helpedrecover nearly 500,000.20days. Officials use this informationto determine whether any claims forrecently deceased Medicaid patients orproviders were submitted after the dateof death. This practice allowed the stateto recoup nearly 300,000 from January2007 to July 2009.22Georgia conducted an analysisto identify hospital claims withreadmissions within three days ofdischarge for the same or a relatedproblem; such claims are supposed tobe considered the same admission forreimbursement purposes. This effortled to the collection of 1.5 million inimproper payments.21New Jersey has started employing aRecovery Audit Contractor (RAC)—aprivate entity that reviews paid claimsand earns contingency fees for improperpayments it retrieves. The staterecovered 4 million in overpaymentsand found 19,000 in underpaymentsbetween April 2011 and June 2012.23(The Affordable Care Act required thateach state Medicaid program use at leastone RAC beginning in 2011.)Kentucky’s Medicaid program receivesdata each month from the state’sDepartment of Vital Statistics onpeople who have died in the past 30WWW.PEWSTATES.ORG/HEALTHCARESPENDING6
COMBATING MEDICAID FRAUD AND ABUSEWhen overcharges are found, officialsfeed the information back to claimsprocessors and often coordinate anyinvestigation or prosecution withMedicaid fraud control units which areadministered by states but funded jointlywith the federal government. Theseunits primarily prosecute wrongdoing,but states may also educate, audit,or sanction a provider or group ofproviders responsible for repeated errors,inaccuracies, or abuse.weather and dates of rule changes, thatmight influence billing or services. Thestate first used this database to identifyfraudulent activity among home healthproviders who submitted claims toMedicaid for services and visits duringextreme blizzard conditions, when travelto patients’ homes would have beendifficult.26Cross-Cutting PracticesMany efforts to ensure programintegrity cut across the areas of providerscreening, prepayment review, and postpayment review. These practices includecoordinating the actions of diversestakeholders, such as representativesfrom various state and federal agencies;engaging and educating providers abouttheir responsibilities; and homing inon providers whom states have deemedhigh-risk.An investigation by Virginia’s MedicaidFraud Control Unit and the FBI resultedin a guilty plea from a woman whosubmitted hundreds of claims for respitecare services that her business had notprovided. In January 2013, she receiveda sentence of 75 months for these andrelated identity theft crimes and wasordered to return more than 600,000to the state.24During its CMS review, LouisianaInvestigators in the District of Columbia cited an example of agencies workingassisted with the July 2012 fraudtogether effectively. Officials overseeingconviction of the owner of two localMedicaid program integrity workedhealth care companies who collectedat least 7 million by submitting falseclaims. She routinely billed DC Medicaidfor up to 2,910 continuous minutes ofIn many states, resources for effortscare for a single patient in a 24-hourto fight fraud and abuse are scarce,period. (There are only 1,440 minutes inso experts recommend that theya day.)25focus on providers who are mostThe CMS identified a noteworthyapproach in Colorado, where the statecreated a database that stores informationabout critical events, such as inclementlikely to engage in SPENDING7
COMBATING MEDICAID FRAUD AND ABUSEwith the staff in the state’s MentalHealth Rehabilitation program toreview 131 providers. They lookedfor problems such as servicesprovided without documentationor by unqualified staff and billingsfor noncovered services. The statesaved about 65 million through costavoidance and recovered 586,000from 2005 to 2007.27In 1999, Washington State began aneffort to employ technology so it couldreduce overpayments and rely lesson resource-heavy examinations ofmedical records and on-site visits. Ituses an online tool to help providerscarefully review their billings beforesubmitting them. The providers answera series of questions designed to helpidentify errors, such as insufficientdocumentation, before claims arereviewed and potentially rejected bythe state. Participation is voluntary, butproviders who decline become primecandidates for on-site reviews. Thesepractices help the state stretch its limitedresources.31In many states, resources for effortsto fight fraud and abuse are scarce, soexperts recommend that they focus onproviders who are most likely to engagein unscrupulous practices. California,for example, has conducted analyses toidentify types of providers who pose ahigh risk of submitting fraudulent orotherwise erroneous claims; as a result,it increased its focus on pharmacies andadult day health centers.28ConclusionBillions of state and federal dollars arelost to Medicaid fraud and abuse eachyear. States have employed an array ofTo verify that providers were billingpolicies and procedures to combat thefor the correct wheelchairs, Georgiaproblem, and many of these practicessent surveys to patients with picturesare catalogued in our online database—of wheelchairs and scooters and askedwww.pewstates.org/Medicaid-fraud—them to circle the type of equipmentto help policymakers and otherthey received. Investigators followedstate officials learn about innovativeup on discrepancies by making on-siteapproaches across the country. Strongervisits.29 The actions of a DC Medicaidstrategies to combat fraud and abuseprovider reinforce the value of such aare vital to ensuring that Medicaid’spolicy. Between 2008 and 2011, thelimited resources support legitimateequipment supplier submitted 100 claims care and better health outcomes for theto Medicaid for the most expensive power millions of Americans counting on thewheelchair, when in fact, patients hadprogram.been given more basic, CARESPENDING8
COMBATING MEDICAID FRAUD AND ABUSEEndnotes1 Improper payments occur when funds go to the wrongrecipient, the recipient receives the incorrect amountof funds (either an underpayment or overpayment),documentation is not available to support a payment,or the recipient uses funds in an improper manner. U.S.Department of Health and Human Services, paymentaccuracy report, udAbuseforProfs/Downloads/fy10txcomppirev.pdf.11 The Pew Charitable Trusts interview with Glenn Prager,Medicaid inspector general for the state of Arizona, May 15,2012.12 Peter Budetti, CMS Center for Program Integrity, SavingTaxpayer Dollars by Curbing Waste and Fraud in Medicaid,June 14, 2012, html.2 Centers for Medicare & Medicaid Services, MedicaidImproper Payment Report: FY 2010 Executive 010 longversion.pdf.3 Starting in 2014, the Affordable Care Act will expand theMedicaid program in states that elect to participate to coverAmericans under age 65 who earn less than 138 percent ofthe poverty level.4 The Pew Charitable Trusts, Health Care SpendingSlowdown? Not for States and Localities, January 2013, -85899445452.13 Joe Gyan Jr., “Louisiana Dentist Put on 5 Years’Probation for Medicaid Fraud,” The Advocate, July 5, ianadentist-put-on-5. The dentist has appealed his conviction.14 Centers for Medicare & Medicaid Services, AnnualSummary Report of Comprehensive Program Integrity Reviews,June 2012, pisummary.pdf.15Texas Health and Human Services, press release, “StateTakes Steps to Improve Oversight of Dental Services,”August 30, 2011, http://www.hhs.state.tx.us/news/release/083011 DentalServices.shtml; U.S. House ofRepresentatives Committee on Oversight and GovernmentReform, “Uncovering Waste, Fraud, and Abuse in theMedicaid Program,” April 25, 2012, d-Program-Final-3.pdf.5 National Association of State Budget Officers, StateExpenditure Report: Examining Fiscal 2010-2012 StateSpending, December 2012, xpenditure%20Report 1.pdf.6 The Pew Charitable Trusts interview with Matt Salo,executive director of the National Association of MedicaidDirectors, April 30, 2012.7 Managed care organizations agree to provide Medicaidbenefits to enrolled residents in exchange for a monthlypayment from the state.8 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, Kentucky Comprehensive ProgramIntegrity Review, October 2010, 09comppireport.pdf.9 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, Wisconsin Comprehensive ProgramIntegrity Review, January 2012, 11comp.pdf.16 Christine Ellis, written congressional testimony, “IsGovernment Adequately Protecting Taxpayers fromMedicaid Fraud?” April 25, 2012, /04/4-25-12-Ellis-Testimony.pdf.17 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, Nebraska Comprehensive ProgramIntegrity Review, December 2010, 09comppirev.pdf.18 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, New York Comprehensive ProgramIntegrity Review, December 2010, 10comppirev.pdf.10 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, Texas Comprehensive ProgramIntegrity Review, April 2011, http://www.cms.gov/19 Pew analysis of annual reports conducted by theOffice of the Medicaid Inspector General from 2008WWW.PEWSTATES.ORG/HEALTHCARESPENDING9
COMBATING MEDICAID FRAUD AND ABUSEto 2011, /194/.20 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, Florida Comprehensive ProgramIntegrity Review, September 2009, mppireviewfy09.pdf.21 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, Georgia Comprehensive ProgramIntegrity Review, January 2012, 11comp.pdf.Integrity Program, California Comprehensive ProgramIntegrity Review, January 2011, 09comppireview.pdf.29 Centers for Medicare & Medicaid Services,Medicaid Integrity Program, Georgia ComprehensiveProgram Integrity Review, December 2008, mpfy08pireviewfinalreport.pdf.22 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, Kentucky Comprehensive ProgramIntegrity Review, October 2010, 09comppireport.pdf.30 The Federal Bureau of Investigation, “Maryland ManSentenced to 19 Months in Prison for Medicaid FraudInvolving Power Wheelchairs and Incontinence Supplies,”January 16, 2013, ontinence-supplies.23 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, New Jersey Comprehensive ProgramIntegrity Review, June 2012, 12.pdf.31 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, Washington Comprehensive ProgramIntegrity Review, January 2011, 09comppireview.pdf.24 United States Attorney’s Office, EasternDistrict of Virginia, “Provider of Home HealthCare Services Sentenced for Medicaid Fraud,”January 22, 2013, 122hollandnr.html.‘About Our Analysis’ box:25 Federal Bureau of Investigation, Washington FieldOffice, “Maryland Woman Convicted of Health CareFraud, Other Charges for Defrauding D.C. MedicaidProgram by Submitting over 7 million in Phony Claims,”July 13, 2012, ubmitting-over-7-million-in-phony-claims.i Centers for Medicare & Medicaid Services, ProgramIntegrity Review Reports List, ity-Review-ReportsList.html.ii Centers for Medicare & Medicaid Services, StateProgram Integrity Reviews, tegrityReviews.html.‘Measuring Medicaid’s Improper Payments’ box:26 Centers for Medicare & Medicaid Services, MedicaidIntegrity Program, Colorado Comprehensive ProgramIntegrity Review, January 2011, 09comppireview.pdf.i U.S. Department of Health and Human Services,payment accuracy report, http://www.paymentaccuracy.gov/programs/medicaid. The error rate is calculated bydividing the improper payment dollars by total Medicaidoutlays during the measurement period.27 Centers for Medicare & Medicaid Services,Medicaid Integrity Program, Louisiana ComprehensiveProgram Integrity Review, March 2010, 09comppirev.pdf.ii The Council of State Governments, UnderstandingPayment Error Rates for Medicaid, January 2012, rstandingpayment-error-rates-medicaid.iii National Association of State Medicaid Directors,NAMD Issues Statement on Recent PERM Report, January2012, http://medicaiddirectors.org/node/300.28 Centers for Medicare & Medicaid Services, MedicaidWWW.PEWSTATES.ORG/HEALTHCARESPENDING10
The State Health Care Spending Project isan initiative of The Pew Charitable Trustsand the John D. and Catherine T. MacArthurFoundation. We help policymakers betterunderstand how much money states spendon health care, how and why that amounthas changed over time, and which policiesare containing costs while improving healthoutcomes. For more information, visitwww.pewstates.org/healthcarespending.The Pew Charitable Trusts is driven by thepower of knowledge to solve today’s mostchallenging problems. Pew applies a rigorous,analytical approach to improve public policy,inform the public, and stimulate civic life.pewtrusts.orgThe John D. and Catherine T. MacArthurFoundation supports creative people andeffective institutions committed to buildinga more just, verdant, and peaceful world. Inaddition to selecting the MacArthur Fellows,the Foundation works to defend human rights,advance global conservation and security,make cities better places, and understand howtechnology is affecting children and society.macfound.org
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COMBATING MEDICAID FRAUD AND ABUSE no way they're going to participate in the Medicaid program," observes Matt Salo, executive director of the National Association of Medicaid Directors.6 Strategies to Combat Fraud and Abuse Fraud and abuse can be committed by both Medicaid providers and patients. But in the project's review of federal
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COMBATING CONSERVATION CRIME LEARNING AGENDA Latin America and the Caribbean Environment November 2020. COMBATING CONSERVATION CRIMES. A LAC Environment Learning Group. COMBATING CONSERVATION CRIME LEARNING AGENDA Latin America and the Caribbean Environment. Photo by Eric Stoner Forest Canopy in Pará state Brazil. Purpose and Content. Purpose .
Abuse Hotline (Hotline). This 2021 edition of the State Fraud, Waste and Abuse Hotline Policies and Procedures Manual (Manual) reflects appropriate revisions consistent with Executive Order Number 52 (2012). The Manual was created to assist internal auditors, agency heads and Office of the State
What is fraud and abuse? 19 Billion: Medicaid improper payments FY2012 Fraud: misrepresentation of services rendered Abuse: practices that, either directly or indirectly, result in unnecessary costs to the program Waste: inaccurate payments for services, such as unintentional duplicate payments 333 3
French (2004) found that animal abuse can be an indicator of child abuse. Animal abuse has come to be seen as part of a continuum of abuse within families. Animals may be used to coerce children into silence. Some abusers even kill animals in front of the child and threaten that the child or other family members will be next. Animal abuse and
are victims of abuse. 1 › 1 in 10 persons over the age 60 are victims of elder abuse. 2 › Victims of elder financial abuse in U.S. lose close to 3 Billion each year. 3. 1. National Center of Elder Abuse:2005 Elder Abuse Prevalence and Incidence. 2 . National Institute of Justice: Elder Abuse as a Criminal Problem. 3
or threatened with physical or mental harm by the acts or lack of action by a person responsible for the child's care. Each state has its own laws concerning child abuse and neglect. There are several forms of abuse: physical abuse, emotional abuse, and sexual abuse. Child neglect is a form of abuse that occurs when a person responsible
Soldier’s level of functioning as of the last developmental counseling session IAW AR 380-5, paragraph 5-5; and AR 25-2, paragraph 4-5. 2. First line leaders should: a. Conduct counseling sessions addressing the domains identified on the USA SLRRT with all Soldiers for whom they are responsible IAW paragraph F: Policies and
