Unlocking Aba Therapy Reimbursement: Navigating The Insurance Billing Maze

Billing insurance for ABA therapy can be a challenging process due to the complexity and constant evolution of billing codes. When health insurance first recognised ABA therapy as a medically necessary treatment, there were no specific billing codes, leading to confusion and inconsistent claims data. To address this issue, the Association for Behavior Analysis International (ABAI) requested the CPT Editorial Panel to amend billing codes, resulting in the introduction of new CPT I and CPT III codes in 2019. These codes aim to standardise ABA billing and prove the medical necessity of various treatments.

Today, there are 16 CPT codes that guide ABA therapy billing, but many therapists still face challenges due to code complexity and procedural issues. Keeping up with the latest CPT codes is essential to avoid claim denials. In addition, understanding insurance coverage, credentialing, and becoming an in-network provider are crucial steps to ensure smooth billing and reimbursement for ABA therapy services.

Understand insurance coverage for your clients and state

Understanding insurance coverage for your clients and state is essential when billing for ABA therapy. While most insurance plans cover ABA therapy, the specific coverage varies depending on the client's insurance plan, their state, and their age. Thus, it is crucial to understand the insurance landscape in your state and confirm your client's coverage before providing services. Here are some key points to consider:

Insurance Coverage by State:

As of 2022, all 50 states in the US have implemented laws mandating insurance coverage for ABA therapy, but the extent of coverage differs across states. For example:

• California requires health insurance policies to cover "behavioral health treatment for pervasive developmental disorder" without a maximum age limit.
• Delaware mandates coverage for ABA therapy up to $36,000 per year for individuals under 21.
• Florida has a similar mandate, covering ABA therapy up to $36,000 per year, with a $200,000 lifetime maximum.
• Texas, New York, Illinois, and Pennsylvania have comprehensive autism insurance laws that include coverage for ABA therapy.
• Idaho and Wyoming do not have mandates for private insurers to cover ABA therapy, while other states have age limits or coverage caps.

Understanding Client's Insurance Coverage:

Before providing ABA therapy services, it is crucial to confirm your client's insurance coverage to avoid issues with claim denials or delays. Here are some steps to take:

• Verify if your client has health insurance and understand how their plan covers ABA therapy.
• Check if there are any age limitations, maximum benefit caps, or restrictions on the duration of treatment.
• Contact your client's insurance provider to confirm coverage details, as plans and policies can vary.
• Obtain prior authorization or pre-certification if required by the insurance company.
• Understand the client's deductible, copayment, or coinsurance responsibilities.
• Inquire about in-network providers and whether your practice is recognized by the insurance company.

By understanding the insurance coverage landscape in your state and your client's specific plan, you can ensure a smoother billing process and minimize potential issues with insurance claims.

Ensure you're credentialed

Credentialing is a crucial aspect of running a behavioural therapy clinic. It is the process of assessing the background and legitimacy of a medical practitioner and establishing the qualifications they require to become licensed professionals. ABA therapists are board-approved behavioural analysts and must meet credentialing requirements to practice. Credentialing allows behavioural therapy clinics to legally serve new patients and receive payments for their services.

The process of getting credentialed can be lengthy and complicated. It is recommended to start the process as soon as possible, especially for new medical practices. The first step is to apply for a National Provider Identifier (NPI). This requires information such as a social security number, BCBA certificate number, and Taxonomy code for behavioural analysts. The NPI is usually acquired within a day and is essential for receiving reimbursements for ABA services.

The next step is to become a member of The Council for Affordable Healthcare (CAQH). To do this, a medical practice must receive an invitation from an insurance provider. Once the firm can log in to the CAQH system, they must submit various information, including employment history, references, resumes, certificates, and educational history. After completing the application, insurance companies will access and verify the information.

The whole process can take around 90 to 120 days. It is advisable to seek help from third-party professionals who can guide you through the process and ensure all requirements are met.

By getting credentialed, ABA therapists can provide care to patients with ABA health insurance coverage. It also allows medical practices to send bills to insurance providers electronically, receiving payments faster and more conveniently than through traditional paperwork.

In addition to credentialing, it is important to research the requirements of each insurance company. Some states only credential Licensed Providers, and some insurance companies are not accepting new ABA providers. It is also crucial to determine your fee schedule before negotiating with insurance companies. This fee schedule will be your published rates and should be consistent for all insurance companies.

Overall, ensuring you are credentialed is a vital step in the process of billing insurance for ABA therapy. It allows you to legally provide services and receive payments from patients. The process can be complex, so seeking third-party support can be beneficial.

Become an in-network provider

Becoming an in-network provider is a great way to expand your patient base and ensure that your services are accessible to a wider range of patients. It is also beneficial for both providers and patients, as it can result in lower out-of-pocket costs for patients and increased patient volume for providers. Here is a detailed guide on how to become an in-network provider:

Obtain Necessary Credentials:

Get a National Provider Identifier (NPI) and other necessary credentials. An NPI is crucial for healthcare providers planning to participate in insurance networks. Insurance companies and government programs like Medicare require an NPI to bill for services. Additionally, ensure you have the required licenses and certifications to practice in your state.

Get Malpractice Insurance:

Malpractice insurance provides coverage if a patient sues you for medical malpractice. Insurance companies often require this as it ensures that their network providers are adequately covered. Malpractice insurance can protect you from financial ruin by covering legal expenses and damages.

Make a List of Insurance Companies:

Research and select insurance companies that are widely accepted by patients in your area. Consider factors such as geographic location, patient demographics, insurance plan types, reimbursement rates, and administrative requirements when making your list.

Open a CAQH Account:

The CAQH application streamlines the process of becoming an in-network provider. It allows you to submit your information once to be shared with multiple insurance companies, instead of filling out separate applications for each insurer. Insurance companies use the CAQH application to verify your education, licensure, certifications, and work history.

Contact Insurance Companies:

Reach out to the insurance companies you wish to work with after completing your CAQH application. Evaluate the contract and fee schedule before registering as a provider. Ensure you understand the contract requirements and that they align with your business needs.

Follow up with Insurance Companies:

Insurance companies sometimes misplace provider applications or leave them pending. To avoid delays, contact the insurance companies regularly to check on the status of your credentialing applications.

Response from Insurance Companies:

Once the review process is complete, insurance companies will notify you of their decision to approve or deny your application. If approved, you will be added to their network of approved providers. If denied, they will provide a reason and may allow you to appeal or submit additional information.

Becoming an in-network provider involves a detailed process, and it is essential to carefully follow each step to ensure a successful application.

Have the right system in place for filing claims

Once you have been approved as a credentialed provider, you might think it's 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 of 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.

How to implement a practice management system

A practice management system is a software solution that helps healthcare providers manage day-to-day operations. It can help you streamline your practice's front- and back-office tasks, such as scheduling appointments, managing patient records, and handling billing and payments.

When choosing a practice management system, consider the following:

• Cost: The upfront cost of the software, as well as any ongoing fees for maintenance, updates, and support.
• Ease of use: Choose a system with an intuitive interface that is easy for you and your staff to use.
• Integration: Look for a system that integrates with your other software tools, such as your electronic health record (EHR) system.
• Security: Ensure the system meets industry standards for data security and privacy, such as HIPAA compliance.
• Customization: Look for a system that can be customized to your practice's specific needs, such as adding your logo or branding.
• Reporting and analytics: Choose a system that provides robust reporting and analytics capabilities to help you track key metrics and make informed decisions.
• Customer support: Ensure the vendor offers timely and responsive customer support to help you resolve any issues that may arise.

By implementing a practice management system, you can streamline your billing and claims submission process, reducing the risk of errors and denials. This will ultimately save you time and improve your cash flow.

Understand the different categories of ABA billing codes

There are two broad categories of ABA billing codes. The first addresses the client assessment before developing an ABA therapy plan or curriculum. The second category covers different ABA treatment services.

Initial Behaviour Identification Assessment

The first category of ABA billing codes addresses the client assessment before developing an ABA therapy plan or curriculum. The initial behaviour identification assessment is billed under code 0359T and can have follow-up procedures. These include observational and exposure behavioural assessments, which may have different billing codes based on the duration of the session.

Observational assessment sessions lasting less than 30 minutes are billed under code 0360T, while those exceeding 30 minutes are billed under code 0361T. Similarly, exposure behavioural assessments are billed under codes 0362T and 0363T, depending on whether they last less or more than 30 minutes, respectively.

ABA Treatment Services

The second category of ABA billing codes covers different ABA treatment services. Codes 0364T to 0374T fall under this category and address various aspects of ABA therapy.

Codes 0370T to 0373T deal with therapies that are not subject to time constraints, such as providing guidance to families without the patient being present. On the other hand, codes 0373T and 0374T are used for treatments that are billed differently based on the duration of each visit.

It is important to note that these billing codes are subject to change over time, and keeping up with the latest CPT (Current Procedural Terminology) codes is essential for accurate and efficient billing practices.

Frequently asked questions