How-to Guide for Processing ABA Insurance Claims
By Christan Griffin, M.Ed., BCBA, LBA
The practice and service model of ABA is still considered in the preliminary stages of development. Policies created or modified are done to protect the consumer and the practitioner. Change and modifications are inevitable in any company or field and are typically initiated to improve a flawed or outdated process. Beginning in the early 2000s, activists tirelessly worked with state legislators and congress members to have insurance approve ABA as a medically necessary treatment for ASD.
It was not until 2010 that some health insurance agencies recognized ABA as a necessary medical treatment and included the benefit in health plans (“A decade,” n.d.). In October 2019, after almost 20 years of fighting for children’s rights to receive medical treatment for ASD, the last state was mandated to provide some level of coverage for ASD, including ABA (Autism insurance coverage now required in all 50 states, (Bernhard, 2019). There is still more work to be done, but the advances in coverage for children with Autism are nothing short of incredible.
Billing 101: ABA Claims Processing
Mandated ABA treatment
If you know a behavior analyst or two, you will agree they are a committed, steadfast, and benevolent group of individuals. The Autism Community, including caregivers, researchers, professionals from many backgrounds, lobbyists, advocates, and behavior analysts, have banded together to meet the needs of this underserved population.
As more research was released that rendered ABA an empirically supported treatment proven to alleviate symptoms associated with autism spectrum disorder, it was not surprising to see the Autism Community call to action changes to policies governing the approved treatments for ASD. Let us review the claims process in more detail and recommendations from the content experts on managed billing.
Claims Cycle Review
- Determine eligibility and demographic information to ensure the service is covered with the client’s health plan. Next, file the claim with the payer. The claim is completed and either sent to the payer directly or sent to the clearinghouse. The clearinghouse will review a claim for accuracy, determining the next steps.
- If the claim is free from errors, it can be sent directly to the payer. It is rejected, and there will be no explanation of benefits since the clearinghouse is the “middle person” vs. payer. Claims rejected at this stage can be considered an opportunity since they can be rectified before submission to the payer.
- The payer will review the claim, accept it, and process it in this phase. A claim denied at this stage is associated with the payer and directly affects the reimbursement of the service provided.
- Settlement or denial information is issued to the provider, along with payment (if applicable). An explanation of benefits (EOB) is given to the client.
- Any remaining balance would be the responsibility of the client. Client’s typically like paying through online means, so having software to support those transactions is beneficial to collect the remaining balances owed.
What is a Claims Cycle?
How Can I File A Claim?
There are a few different options for filing a healthcare claim. Follow along below as each of the four methods is reviewed to identify which one(s) might be the best option for you and your ABA agency.
Option 1: Mail-In Claims – Form 1500
- Certified/Tracking: Whenever mailing supporting documents or claims, send them through certified mail with a tracking number.
- Supporting Documents: Whenever submitting a claim through the mail, ensure that you have included all the supporting documents. If you are resubmitting a claim, make sure you include any documents from the initial claim, such as the EOB. (Stall, Brinkman & Padula, 2021)
This method is not ideal. The need to mail a claim could be because the payer does not accept claims through the clearinghouse or may not have a portal (Stall, Brinkman & Padula, 2021).
Option 2: Electronically Online – Form 837p or 837i
- Online Portal: Most payers will have an online portal where the provider can create an account. The ABA provider would then fill out the corresponding form and upload it directly through the online portal.
Be Vigilant: Pay close attention to the accepted forms through the online portals. Some ABA providers will fill out a 1500 and upload it, and the payer will accept it, while others may not. Note,
- “837p = HIPAA secure claims format for professional claims. 837i = HIPAA secure claims format for institutional claims.” (Stall 2021).
Be prepared for variations in how the payers are requesting claims submissions. Have all necessary data, reports, and documents on hand and ready to submit with the claim.
Option 3: PMS/EHR/CLEARINGHOUSE
- Providers can create and submit claims through the PMS or EHR systems connected to a clearinghouse.
- The clearinghouse completes editing first (i.e., before the claim goes to the payer) to ensure the claim is clean when the payer receives it.
- The ABA providers can set up PMS/EHR system with the Clearinghouse feature as an additional denial avoidance strategy. Still, fees would apply for claim scrubbing and submissions through the clearinghouse.
Claims can be sent back for edits from the clearinghouse for claims’ payments and denial information if the claim is denied after the payer processes it. (Stall, Brinkman & Padula, 2021)
Option 4: Option 4: THIRD-PARTY VENDOR
- Ensure that the third-party vendor is up to date on HIPAA regulations and guidelines to protect your practice/business.
- ABA providers should execute BAA (Business Associate Agreements)
- Terms (statement of work) should be clearly defined – roles/responsibilities of third-party vendors included in a signed agreement.
- KPI driven results – check in weekly or monthly to discuss RCM KPIs defined
- Automation capabilities for billing should be provided by third-party vendors (i.e., claim submission EDI, ERA (electronic remittance), and workflow automation.
Partnering with a third-party vendor specializing in billing management and revenue cycle processing specifically for ABA agencies allows the practice to focus on providing and delivering care. There are other options available for ABA providers who are ready to move on from the aversive feeling of ongoing administrative work, denied claims, or missed opportunities for maximum reimbursement (Stall, Brinkman & Padula, 2021).
Therapy Brands, CodeMetro’s parent company, and its partners are knowledgeable on the revenue cycle and have helped businesses maintain, and even surpass, the industry standard of 90-95% clean-claim submissions. Practice management solutions such as AccuPoint, WebABA, CodeMetro, and DataFinch offer many advantageous PMS and RCM options for ABA practices, both small and large scale.
The field of Behavior Analysis has demonstrated an unwavering level of dedication to grow professionally, maintain good ethics and systematize a standard model of care to decrease the probability of adverse treatment effects on patients. Learning the standardized CPT codes will help ensure services can be provided consistently and claims will be paid, allowing ABA providers to continue to operate and take on new clients.
While revisions to standard operating systems are involved during the initial stages, consistent implementation and sound knowledge of procedures will support the reform. Streamlined workflows RCM are essential to preserving the financial stability of ABA organizations. The ABA community has successfully demonstrated structural and operational transformations thus far. Likewise, the evolution of the BACB is comparable to the progression of the ABA billing process. When changes happen, we often get discouraged, which is understandable. Still, an excellent reminder for all ABA providers pioneering these changes is to look at the trend of success thus far. We have a consistent upward trend, and we all know how upward trends make an ABA provider feel!
Additionally, partnering with a third-party vendor specializing in billing management and revenue cycle processing specifically for ABA agencies allows the practice to focus on providing and delivering care, which is what you do best! There are other options available for ABA providers who are ready to move on from the aversive feeling of ongoing administrative work, denied claims, or missed opportunities for maximum reimbursement (Stall, Brinkman & Padula, 2021). Explore this option today by setting up a free billing consultation with Therapy Brands.
Want to learn more? Therapy Brands can help!
Therapy Brands is a leading provider of Practice Management Solutions, including RCM, explicitly developed for ABA organizations, and delivered by one of many PMS organizations nestled under the umbrella of Therapy Brands. The most significant part of Therapy Brands being the motherboard connecting ABA agencies to a variety of PMS partners is that the services can be individualized and tailored to fit the needs and size of any ABA agency.
Schedule your call today for a FREE billing consultation and see what Therapy Brands can do for your ABA organization!
What used to be only available for the more established companies now has options for everyone. Managed billing ABA providers the reassurance they are maintaining stable financial health while spending more of their valuable time with clients.
What used to be only available for the more established companies now has options for everyone. Managed billing ABA providers the reassurance they are maintaining stable financial health while spending more of their valuable time with clients!
Download Our In-Depth ABA Claims Processing White Paper
A Decade of Progress – ABA Billing Codes. (2022). Retrieved 31 January 2022, from https://www.ababillingcodes.com/about/history-2/
Bernhard, B. (2019). Autism Insurance Coverage Now Required In All 50 States. Retrieved 1 February 2022, from https://www.disabilityscoop.com/2019/10/01/autism-insurance-coverage-now-required-50-states/27223/
Stall, D., Brinkman, M., & Padula, N. (2021). Billing 101: Claims Processing – Ensuring Efficient Management of Your Revenue Cycle. Presentation, webinar.
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How Retention and Payroll Impact the Financial Health of Your ABA Practice
The industry has changed drastically for ABA practice financials since the beginning of 2020. Providers are scrambling to recover from the pandemic as community healthcare and school-based settings were among those impacted most. Not only did a magnifying glass on public health and a decrease in in-person interactions change how ABA providers deliver care, but the conditions to which the field had to adjust drastically impacted their bottom line.
Providers across the country are wondering what their next steps should be in response to fluctuating cash flow. The Behavioral Health Center of Excellence (BHCOE) suggests that an estimated 76% of providers are currently experiencing at least a 50% drop in their revenue compared to what they were bringing in before the start of the pandemic.
While COVID-19 is still impacting the field, there are steps providers can take to encourage the growth of their ABA practice financial health.
Improving the Financial Health of Your ABA Practice
Focus on Retention
There are two areas of retention that impact your ABA practice’s financials.
Most ABA providers should be familiar with the term “client retention” or “client retention rate.” This refers to the rate at which a provider is able to keep their clients. It is calculated by averaging how long a client is expected to work with you versus when/if they self-terminate (or leave your practice). There are a number of reasons why a client might decide to leave a provider. While those are important, the financial issue is that low client retention can be detrimental to your bottom line. Improving this is an efficient and effective method for addressing ABA practice financial health.
Benefits of Client Retention
Loyalty is an incredible thing for a provider’s bottom line. Loyal clients are more likely to keep coming back to your ABA practice and refer others to you for help as well. Increasing client retention means that you have established the level of loyalty that keeps patients coming back for more instead of leaving to go somewhere else.
Reduced Marketing Costs
Providers that are struggling to keep their client retention rates up know just how expensive it can be. If patients are leaving, that means your ABA practice has to work harder to bring new patients in. This causes marketing costs to skyrocket as your try to drum up new business. Increasing your client retention rate reduces the need to market heavily, cutting those costs and improving ABA practice financial health.
With loyal patients who you know are not going anywhere, you can look more accurately into the future. Forecasting is essential to running any practice. With higher client retention rates, providers can better predict future expenses and revenue growth. Without this window into what is to come, providers are not able to plan which leads to wasted resources and a hit to ABA practice financials.
Communication is everything when building rapport with patients and increasing the loyalty they feel toward your practice. Effective communication builds client engagement and satisfaction, which ultimately keeps them coming back for more. The better communication and engagement that exist between your ABA practice and your clients, the higher the retention rate providers will achieve.
Clearly Set Billing Expectations
Another prevalent reason that clients leave a provider is that they were caught off guard by the cost of their care. This happens when they do not have a firm understanding of your billing process. Before sessions start, providers need to outline billing expectations in a way that the client clearly understands. This should include payment policies, the cost of services, what types of payment you take, and any other billing information. Keeping them 100% informed will prevent them from ever being caught off guard by their role in the billing process and increase client retention.
ABA therapy is an extremely involved area of behavioral health that requires a massive time commitment. When patients do not understand or know what to expect regarding scheduling, it can feel like cause for premature termination. Just like billing, scheduling expectations should be set from the start. Providers and their clients need to sit down and determine what schedule will work for them and utilize digital tools that make scheduling a breeze.
Employee retention is the second type of retention that impacts ABA practice financial health. This refers to the rate at which employees leave their role at your practice. Onboarding new ABA practice employees are expensive and challenging. Increasing employee retention can also have a positive impact on your bottom line.
Impact of Employee Retention
Lower Onboarding Costs
The average cost to onboard a new employee across all industries is roughly $4000. In the field of ABA therapy, this cost is higher due to the fact that professionals need more in-depth training compared to other industries, like retail. It can take years for new therapists to reach their fullest potential and productivity. By keeping your employee retention rate high, you can avoid costly onboarding processes while seeing the return on your investment for those you trained, who stay on board.
Shortage of ABA Professionals
Another reason employee retention matters is because that there is a shortage of ABA professionals in the United States. A recent study compared the per capita supply of certified ABA providers for each state and found that 49 states fell below the benchmark set by the Behavior Analyst Certification Board.
Maintaining high employee retention rates prevents providers from having to go on the search for new professionals during a time where there are not many to spare.
Use Quality Digital Tools
The tools your practice uses on a daily basis for things like scheduling, planning, payroll, and more all have an impact on the employee experience. To reduce burnout across your organization, ABA practices need to make sure they are using digital tools that simplify some of the processes that have overwhelmed providers in the past.
Take Steps to Decrease Burnout
“Burnout” refers to the mental or physical exhaustion that an employee feels and is a direct result of the efforts they exert in the professional setting. Digital tools can be a great way to simplify certain processes, but there are other ways to reduce burnout as well. ABA practices need to make sure they are giving their employees time for self-care and work-life balance as well as space to express concerns and make positive changes.
Perfect Your Payroll Process
It may be shocking to hear, but 49% of employees say they will begin their search for another job after just two payroll errors. Making sure your employees get the compensation they deserve for their hard work is an important part of making them feel accomplished in their job and is a motivation for them to stay at your ABA practice.
Get Serious About Your ABA Practice’s Payroll
Expanding on the importance of payroll, providers need to get serious about how they are managing it. Payroll is a necessary, yet burdensome process that can cause huge ABA financial headaches.
Common Issues with Payroll
81% of small and mid-market practices handle payroll in-house. They do this without the internal support structure that is needed to deliver perfect results every single time. This makes payroll a time and resource-consuming process that ends up stretching ABA practice finances too thin and increasing errors across the board.
As mentioned earlier, payroll errors can cost an ABA practice its employees. Making sure that your practice is at the top of its game when it comes to payroll is integral for increasing employee retention.
Integrated Payroll Software
The best solution for ABA practices that need to improve their payroll and financial health is to adopt a fully integrated payroll solution. A tool like this helps providers avoid costly errors that waste their time and burden their employees. The right solution automatically tracks time worked, overtime, pay periods, pay ranges, and more for every practitioner within the organization.
Another source of payroll headaches includes the scheduling process. To prevent errors in payroll, like too much overtime or incorrect timestamps, providers need to consider an integrated scheduling component. This helps payroll solutions accurately track and prevent costly mistakes within their calendar process.
The impact that retention and payroll have on the ABA practice financial health is immeasurable. Providers that pay close attention to these areas of their practice will start to find that they are growing past the financial challenges and trials they faced during the pandemic. The key to strong ABA practice financial health includes updated digital tools as well as the utilization of revenue cycle management services.
Interested in more financial resources for your ABA practice?
Download a copy of our white paper on financial tips for your organization by submitting the form below.
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ABA Billing Codes and Challenges for Providers in 2021
ABA billing codes do not have to put a strain on your therapy practice. For many providers, keeping up with ABA billing codes, changes in regulation/coverage, and chasing down payments has become a burden. It sometimes feels as though there are so many details to keep track of that it would be impossible for you to keep up.
The issue is that the role billing plays within your practice is paramount to your ability to work with the clients. What is causing strain on your practice is the fact that you have yet to perfect the billing process. The use of ineffective billing solutions is what is holding your practice back from a streamlined, effective, and flourishing billing process.
The good news that with the right technology or partnerships, your practice can finally tackle the ABA billing codes and challenges that have held you back for so long.
ABA Billing Code Challenges
One of the most integral components of your claims process is coding each claim accurately with the correct ABA billing code. Doing so will offer you your best chance at an approved claim. This is one of the biggest challenges for providers offering ABA therapy. ABA billing codes are complex, specific, and require great understanding. With clients to focus on, it can be difficult to be an expert on billing as well.
Even when ABA billing codes are accurate, denials still happen. One of the biggest challenges that ABA therapy providers face is their denial management process. When a denial is not caught, corrected, and submitted within the required time-frame, revenue is lost.
ABA Billing Codes
The most-used ABA billing codes include:
97151 – Behavior Identification Assessment
0362T – Exposure Behavioral Follow-Up Assessment
97155 – Adaptive Behavior Treatment w/ Protocol Modification
97156 – Family Adaptive Behavior Treatment Guidance
97157 – Multiple Family Group Adaptive Behavior Treatment Guidance
0373T – Exposure Adaptive Behavior Treatment with Protocol Modification
97152 – Observational Behavioral Follow-Up Assessment
97153 – Adaptive Behavior Treatment by Protocol
97154 – Group Adaptive Behavior by Protocol
97158 – Adaptive Behavior Treatment Social Skills Group
Improving Your Claims Process
In order to improve your claim and denial management process, providers should access the following tools and services.
Built-in End-to-End Billing Software with Revenue Cycle Management Options
What many providers do not realize is that they do not have to try and become ABA billing experts on their own. In fact, providers with the highest-functioning billing processes outsource claim and denial management to a qualified practice management or revenue cycle management billing partner.
The right tool will simplify your billing process and save time by generating reliable electronic claims, easily posting payments/adjustments, tracking the status of claims, and much more.
Billing software, such as NPAWorks by CodeMetro, can take over your claim/denial management to ensure you optimize your revenue cycle and fortify your bottom line. They will scrub each claim for errors such as incorrect ABA billing codes and track the claim to make sure you are receiving a high number of timely payments. On average, ABA practices collect on 80% of their insurance claims. NPAWorks has an average claim clearance rate of 95%…just think what your practice can do with the extra revenue!
With the right partner of either managed billing or ABA billing software, your practice can tackle the burden of ABA billing codes and claims while building confidence in its bottom line. To schedule a consult with an NPA Works billing expert that is ready to help you, click here.
This post is for informational purposes only and is not meant to be used in lieu of practitioners own due diligence, state and federal regulations, and funders’ policies.
5 Ways ABA Therapists Can Save Time on Insurance Billing
You may know, or at least suspect, that you need a guide to insurance for ABA providers. We agree and we want to help you make billing with insurance as painless as possible. That’s why we’ve provided these 5 tips to help you start improving the way you do ABA insurance billing.
Tip #1: Make sure you understand insurance coverage as it relates to your clients and your state.
Not all insurance plans cover applied behavior analysis (ABA) therapy in the same way. One way to make sure you are eligible to receive payment for services rendered is to confirm whether your patient has health insurance and how it covers ABA therapy. As of October 1, 2019, 50 states and the District of Columbia mandate insurance coverage for ABA therapy; however, not all 50 states cover ABA therapy at a universal level.
- California, for example, requires that every health insurance policy must cover “behavioral health treatment for pervasive developmental disorder.” (Cal. Insurance Code Sec. 10144.51 and Sec.10144.52 2011 Cal. Stats., Chap.650; SB 946) Such coverage does not require that the benefits paid exceed the federal essential health benefit level under the Patient Protection and Affordable Care Act.
- California also requires ABA therapy coverage for a person of any age under the same rules that apply to other medical infirmities.
- Other states mandate a specific age limitation. In Maryland, for example, the age limit is 19; in others, like Delaware, it’s age 21.
- Florida mandates that health insurance plans cover ABA therapy but limits that coverage to $36,000 per year, subject to a $ 200,000-lifetime maximum.
- In addition to maximum age thresholds and maximum benefit limitations, insurance company policies may also restrict how long a person may receive ABA therapy treatment, restrict in-home ABA therapy, and so on.
These variations make it especially important that you know the rules as they apply in your jurisdiction. Always take things a step further and speak with your clients’ provider to verify coverage before you start a session.
Tip #2: Make sure you're credentialed.
You have to check your clients’ coverage, but you also have to make sure your practice is recognized by the insurance company. Every insurance carrier has its own conditions and prerequisites that a therapist must meet before the company will pay for ABA therapy by that provider. The conditions include credentialing for the therapist.
Credentialing means providing documentation in support of your application for approval, such as your medical licenses, a salient overview of your education and work-life (curriculum vitae or C.V.), proof of medical malpractice insurance and its limits, a list of hospitals where you have admission privileges — to name a few. It can take about a month for the initial credentialing process to gather the necessary information and responses from schools and boards and other references. After your practice completes the initial vetting process, the insurance company will verify the sources on your application and then submit your application for approval or disapproval to a credentialing committee.
Credentialing is critical for a medical provider’s eligibility to accept payment from a third-party payor (the insurance company).
Tip #3: Become an in-network provider.
Patients covered by what’s known historically as an indemnity plan can go to any doctor they want. On the other hand, patients covered by a preferred provider organization (PPO) or a health maintenance organization (HMO) must receive their health insurance from a preferred provider or the HMO’s staff. A preferred provider is also known as a provider that operates in-network. Insurance plans reimburse in-network providers at a higher rate than out-of-network providers. Sometimes they won’t pay out-of-network providers, making the patient 100% responsible for the cost of services rendered.
In-network providers (physicians, hospitals, and labs) sign a contract with the health insurance carrier to provide services at a discounted rate. In return, the insurance company provides an ongoing patient stream which requires that patients use the insurance company’s preferred provider list in order to receive maximum payment. This agreement allows the health provider to spend less time searching for new patients.
Providers are selected based on education, credentialing, the size of the discounted fee the provider sets for the covered patients/insurance company, and the provider’s availability to accept new patients. After application approval, the insurance company will offer a contract to the provider. In-network providers must also agree to follow all the rules the insurance company sets.
Tip #4: Have the right system in place for filing claims (and getting paid).
Once you receive approval as a credentialed provider, you might think it a simple matter to submit invoices for services rendered. However, if you don’t have a practice management system in place that also covers billing, then claims submissions (and payments) can become a hassle.
Each insurance company has its own forms that providers must complete. Each claim form requires appropriate medical coding for the service performed and other pertinent information about the client and your practice. Therefore, you must maintain your updated familiarity with the Current Procedural Terminology (CPT) codes that apply to ABA therapy services. You must also maintain updated records on your client’s personal contact information and insurance information.
If any of the information completed on the form is in error, the company will deny the claim. Companies also have filing deadlines to which providers must adhere or the company will deny the claim.
Tip #5: Don't ignore claim denials.
If a client’s insurance company denies your request for payment, under certain circumstances, you may appeal the decision. So, it’s important to know the appeal procedures of that particular insurance company. Generally, you may appeal if:
- you don’t know why the claim was denied;
- you received payment but it was in the wrong amount;
- you disagree with the insurance company that the patient had a disqualifying preexisting condition;
- you disagree with the insurance company’s determination that the services were not “medically necessary”;
- the company’s payment does not reflect special circumstances that required complicated medical services;
- your payment was denied because you did not obtain pre-certification but you had determined special medical conditions precluded pre-certification.
Alternatively, you can secure services that will review and fix claim denials for you (and even lower the occurrence of denials in the future).
A few final thoughts for a successful relationship with insurance companies.
Bear the following suggestions in mind when working with insured patients:
- Make sure you collect all co-payments and deductible amounts as required under the patient’s policy at the time of service or in weekly or monthly invoices covering those services. This is your responsibility as a provider. The insurance company will not collect those for you.
- Document the name and phone number of any insurance company staff member to whom you speak.
- Take good notes of your conversations and provide all documentation within the time frames requested.
Ready to Get a Handle on Your Billing?
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ABA Billing Codes
Applied behavior analysis is a type of therapy for those diagnosed on the autism spectrum and has developmental disorders in categories like language and social interaction.
If you’ve tried looking for information on autism CPT codes and other codes related to applied behavior analysis in the past, you know it can get confusing quickly. Especially with all the current changes in applied behavior analysis billing codes that are happening.
ABA CPT Codes for Adaptive Behavior Services – Effective January 2019
The temporary ABA CPT codes have come (mostly) to an end at long last. January 1, 2019 marks an important time for the ABA world—the new CPT codes the American Medical Association CPT Editorial Panel released this August will go into effect.