Applied Behavior Analysis (ABA) therapy is seen as the gold standard for treating individuals with autism spectrum disorder as well as many other behavioral conditions within the mental health sphere. It’s currently estimated that approximately 50% of currently practicing BCBAs have received their certification within the last five years.

While this is certainly something to celebrate for all the patients who need ABA therapy to live their best possible lives, it also means that there are a lot of new providers who might not be fully versed in the arcane and often complex insurance submission processes. Compounding this is that insurance submission review isn’t mandated as part of the typical ABA curriculum.

This can leave a large segment of the industry with questions about variability in quality, style, and data in treatment plans that need to be submitted for authorization. This in turn can lead to an overly lengthy review process for health plans.

In reality, there are often significant discrepancies between a lot of provider treatment plans, and the sometimes staggering array of symptoms, their severity, and treatment strategies that need documentation according to specific health plan requirements.

This can include the fact that a lot of insurance carriers and public health institutions have complex criteria for defining what constitutes a “Medical Necessity.” So it’s no wonder why so many utilization managers feel like they are being set up with a subjective, inconsistent decision-making process that has substantial gravity in how patients are treated.

To better help demystify the utilization review process, we’re going to have to take a granular look at some of its key components.

The Definition and Utilization of Objectivity

A lot of health plans and managed care organizations utilize different staffing styles when it comes to who can specifically review an ABA treatment plan that’s submitted for authorization of services. This includes ABA treatment plans for patients who are classified with Autism Spectrum Disorder.

Who Performs Utilization Reviews

Depending on the insurance company or the public health institution, the utilization review might be performed by:

  • Certified nurses
  • Social workers
  • Paneled ABA therapists
  • BCBAs

This array of different backgrounds and credentials can lead to a significant level of subjectivity across reviewers, which makes it hard for utilization managers to understand how to properly demonstrate the objectivity of the submitted plan.

Ultimately, the challenge resides in the experience and perspective of the reviewer, who might simply end up comparing treatment plans to the strictest criteria for defining “Medical Necessity.” This can leave some elements of a treatment plan unauthorized of awaiting further clarification of the criteria, despite the patient’s obvious need.

How Utilization Reviews Are Performed

Once the reviewer has been selected they start by individually analyzing each member along with their treatment plan. They also take the time to consider an extensive list of other factors such as:

  • The length of the proposed treatment
  • Historical progress
  • Any past signs of regression
  • Each specified symptom and its documented severity
  • Any co-morbid diagnoses

The possible barriers to treatment

Ultimately, the reviewer’s underlying goal is to ensure the highest quality of care is being provided, as well as making sure that the benefit is being used appropriately for the patient’s needs and coverage. This process often leads to significant disparities in the reliability of the different reviewers based on their own discipline and understanding of the patient’s needs.

The Need For Standardizing the Utilization Review Process

To maintain objectivity and accuracy in the decision-making process reviewers need to make an active effort to reduce opportunities for outcomes that lead might lead to the wasteful allocation of resources. This makes it critically important for health plans to embrace a standardized review process when it comes to providing autism care management.

Consistency in ABA’s therapeutic benefits and the inherent quantifying response rates of treatment go a long way toward ensuring that payers are investing in the highest standards of care. They also need to make sure that every treatment modality provided for service is in fact, medically necessary.

In recent years this has become more standardized by the use of a special decision-making algorithm. It empowers utilization reviewers by giving them the ability to dissect treatment plans, regardless of their overall length or style. The algorithm then lays the pertinent data out in a uniform way with the most relevant information available at a glance. This makes it less time-consuming for the reviewer to analyze and monitor a vast number of members, factoring in their progress, while still reviewing on an individual basis.

The most important factor in this type of model is that it guarantees each treatment plan is still being reviewed on its own merits. While also accounting for important nuances and all the pertinent structured elements that guide the decision and review in a regulated way.

Employing this standardized analysis tool that also ensures the submission of a complete medical record. This means that all the critical information is clearly defined in the treatment plan by the BCBAs in a way that the reviewer can then use to pinpoint important topics, while simultaneously reducing a lot of the communication barriers that often arise between a health plan payer and the patient’s team of providers. This type of analysis also shortens the review process while decreasing latency.

The Importance of Clinical Information

One of the great strengths of ABA therapy is that it uses a scientific approach to help guide all the treatment modalities. This type of clinical decision-making model translates well to the utilization review process in a way that expedites the process of determining the medical necessity for ABA services. This helps demystify the patient’s needs for the reviewers who aren’t always well-versed in ABA therapy’s finer points

By recognizing the payer’s need to validate the medical necessity criteria helps streamline the utilization review process. This factors heavily into quick approval by the reviewer as they can better understand the overarching goals of the treatment plans being submitted by providers. Even if that treatment plan is seemingly complex.