ABA therapy is seen as the gold standard for treating individuals with Autism Spectrum Disorder, as well as many other serious mental health conditions. Many of these patients have a treatment support team that is overseen by a BCBA or similar expert in the ABA field.

Of course, this also means that a lot of patients receiving ABA therapy need comprehensive coverage. Sometimes this can come from private or employer-sponsored insurance programs. Sometimes it comes from a combination of private health insurance policies. Sometimes it even comes from two parents carrying two different health plans with similar or perhaps even overlapping benefits for their child with ASD.

Though this can also make for some interesting challenges when it comes to coding and medical billing practices for the wide range of professionals in the patient’s support team. At the same time, a lot of insurance companies, public health institutions, and other payer organizations frown upon things like duplicate billing, and overlapping coverage, which can lead to overbilling.

Not only can these incongruities lead to delays, but they can also sometimes result in claim rejections and claim denials for services that should or are technically covered. Compounding this problem is that a lot of times when overbilling occurs, it can draw a red flag for the payer institution. This in turn can result in a tiresome audit that takes even more time and focus away from the patient, while also putting the consistency of your revenue stream at great risk.

The Importance of Coordinating Benefits for ABA Therapy

Coordinating benefits is absolutely critical for making sure that your patient receives the ABA therapy that they need to meet their treatment goals and realize ever-higher milestones. It also helps prevent time-consuming audits and the risk of claim denials.

All this goes without saying that effective benefit coordination also saves parents and caregivers from having to spend money out of pocket just to make sure that the patient receives the important ABA therapy and support they need.

To that point, it helps to understand some of the medical billing industry’s best practices for coordinating benefits for ABA patients.

Techniques For Coordinating Benefits For ABA Therapy

There are a few key scenarios and policies to be aware of. You should also make sure that any of your in-house administrative staff handling coding or medical billing services are also aware of these key points in coordinating patient benefits for ABA therapy.

In a scenario where the individual is covered by their own employer-sponsored policy, this policy will pay before a policy where the individual is strictly considered a dependent. Though this is a less common situation.

If a child or an adult-dependent is covered by more than one individual, then several benefit coordination scenarios can come into play.

If there is a child or adult dependent that is covered by more than one parent or guardian, the plan of the parent or guardian with the earlier birth date in the calendar year is considered to be the “Primary Coverage.” This is known as the “Birthday Rule” and is considered to be the standard practice in medical billing practices, payer practices, and reimbursement from public health institutions.

Though there are some instances, where a court order might supersede the date instead of using the birthday rule. This is generally part of a larger custody case. Just keep in mind that a copy of this court order will need to be presented to all payer organizations as part of the original onboarding process.

If the child or dependent has their own coverage through an employer or some type of post-secondary institution, these plans will always pay before a plan where the child is the dependent.

It’s important to have policyholders complete the coordination of benefits form with each insurance provider. Make sure that they know that they are obligated to disclose all policies during the onboarding process. If a policy change occurs after that, they need to submit that change before further ABA services can be provided.

A lot of claims might be held, delayed, or outright rejected if the coordination of benefits forms is not correctly completed by policyholders. This puts emphasis on the policyholders to communicate changes in coverage to their insurance company at any time.

The majority of children with autism spectrum disorder and other disabilities receive coverage through Medicaid or other public health institutions. In these cases, Medicaid or a state-sponsored health plan is usually considered the payer of last resort. The patient’s parent/guardian is still obligated to disclose coverage to all insurers, as part of the coordination of benefits.

How Outsourcing Medical Billing Services Helps With Coordination Of Benefits

A lot of small practices and ABA solo practitioners find themselves daunted by the volume of paperwork that goes into the coordination of benefits, coding, and medical billing. This is an understandable challenge, considering that their area of specialty and education focuses on helping patients.

When you outsource your medical billing services to a third-party vendor like Operant Billing Solutions, you get the peace of mind that comes with knowing highly trained experts are working diligently to streamline the process. Our specialists use industry-best practices to bear with every single claim. This includes double-checking the coordination of benefits for patients who have multiple forms of coverage from two parents, or benefits from a public health institution.

Our medical billing specialists are well-versed in policies like the birthday rule, who carries the primary coverage, which parent is considered the secondary parent, and the times when coverage from Medicaid or state benefits applies to each patient.

The end result is that you get to spend more time focusing on treating the patient, adding patients to your practice, or expanding the scope of your services. The families of your patients will likely see fewer out-of-pocket expenses, and your practice’s revenue stream will be more consistent.

A lot of ABA providers who outsource their medical billing services find that they can reallocate some of their in-house administrative tasks.