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 Change and modifications are inevitable in any company or field and are typically initiated to improve a flawed or outdated process.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. 

Claim Defined 

Claims Cycle Review 

  1. 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. 
  1. 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. 
  1. 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. 
  1. Settlement or denial information is issued to the provider, along with payment (if applicable). An explanation of benefits (EOB) is given to the client. 
  1. 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?  

Claims Filing   

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 is knowledgeable on the revenue cycle and has helped businesses maintain, and even surpass, the industry standard of 90-95% clean-claim submissions. Our practice management solutions offer many advantageous PMS and RCM options for ABA practices, both small and large scale.  

Key Takeaways 

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.