It’s an unfortunate reality that most ABA therapists experience occasional underpayments for a claim that was submitted in good faith. A lot of these cases occur when a health insurance company fails to accurately reimburse a provider the full requested/contracted amount due to a medical coding error, missing information, or an outright miscalculation by the insurance company.
Compounding this hassle is that some sizable underpayments can lead to long-term financial problems for an ABA practice. Especially if the issue goes unaddressed causing a recurrence of underpayment for future claims.
This requires an ABA practice to develop a clear understanding of underpayments to implement proactive protocols to prevent them.
Top Reasons Why Underpayments Occur in ABA Therapy Claims
Insurance companies are always on the lookout for a reason to deny a claim. This is just one of the many tools they use to mind their bottom line and maximize profits.
Clerical Errors & Missing Information
For their compliance staff and adjusters, any careless billing errors serve as a prime opportunity to either deny a claim or make a partial payment. Some insurance companies will even go so far as to make a partial payment for a simple clerical error, rather than simply ask a question or submit a clarification request to the ABA provider.
Reimbursement Miscalculation
Some insurance companies make an artform out of miscalculating a payment. Sometimes these miscalculations are accidental or due to a lack of information supplied by the ABA provider. Sometimes the insurance company simply comes to a different monetary conclusion as part of the process of reviewing a therapy service provided. Some reimbursement miscalculations are relayed to holes or insufficient coverage in the patient’s insurance policy.
In order to ferret out what the case may be, and what you can do about it, you need to first maintain detailed notes for every therapy session or service provided. You also segregate billable and non-billable hours clearly.
Underpayment Due to Overbilling
As an ABA provider, you need to ensure your administrative staff and billing personnel are using appropriate codes with the correct code modifiers to bill for all services rendered. Anytime someone in your practice accurately records provided services they need to translate them into codes with correct modifiers to prevent overbilling.
By providing administrative staff with retraining updates and holding internal audits to verify or spot-check claims, you start to improve your practice’s procedural consistency.
Contract Misinterpretations with Mediation Terms
A lot of 21st Century business contracts are loaded with arcane jargon that can make it hard to clearly understand some of the finer points. This is especially true with contracts for reimbursement rates in medical billing which are often rife with confusing contract language. This can lead to differing interpretations, with the insurance company seeming to find creative ways to underpay an ABA claim.
Unfortunately, most of these contract disagreements, also have terms requiring legal intermediaries as the only viable solution. This might be a third-party mediation or other lengthy procedural processes that might also incur additional legal fees.
In a time like this, you need to weigh the value of contesting the claim via a legal intermediary. If the disparity in payment is minor and it’s a specialty service that you rarely provide, it might not be financially viable to contest it via a third-party negotiation.
If it’s a service you provide frequently, and you’re concerned about recurring underpayments, then it might make a lot of sense to invoke the mediation terms. Just bear in mind that insurance companies tend to move at geological speeds, and it could take six months to a year to fully reach satisfaction. So, you’ll have to have some sort of plan in place to handle recurring underpayments for this service in the interim.
Tips To Help Maintain Consistent Standards
Consistent standards are your best line of defense against underpayments as well as claim rejections, denials, and delays. Not to mention reducing your risks of drawing a red flag for an audit. This means that you must have clearly defined in-house standards for your clinical and administrative staff. Then be proactive about making sure they are consistently upheld.
Proactive Record Keeping
The first step in maintaining consistent standards to prevent underpayment is to keep a clear record of sessions making sure that all required fields and critical details are. This means that each therapist and staffer in your practice must know what items are integral to the session notes.
After the ABA therapist has completed a note set, it needs to be assessed promptly to ensure that all the appropriate CPT codes and modifiers were used correctly. It’s also a good idea to perform spot checks to ensure that your workers are familiar with CPT standards as well as factors that might affect the usage of correct modifiers.
Perform Periodic Contract Reviews
Complacency can be a thief. Especially if you’re just making assumptions that one insurance carrier has the same rules and procedures as the others with which you are paneled. Make sure to schedule periodic reviews for all your contracts with insurers to clearly understand how much they have agreed to pay for each service.
They also make sure to match the codes and the modifier you have provided with the agreed-upon compensation amount. This is another layer of due diligence that will go a long way toward reducing underpayments.
Contact Insurers When Necessary
You might have to contact an insurance agency to confirm or renegotiate prices. Some public health institutions like Medicaid also have online resources to help make this process simple.
However, a lot of private insurers are less well-equipped. Have knowledgeable contacts at these insurance companies to streamline the information-gathering process.
The Benefits of Using a Third-Party Medical Billing Service
The process you have to go through to reduce the risk of accidental underpayment, claim delays and deal with slow-moving insurance carriers can be cumbersome and tiring. To the point that it can even be a disturbance to your clinical operations and treating patients.
One way that a lot of solo and small ABA practices use to reduce the incidence of underpayment is to contract their medical billing services through a third-party agency like Operant Billing Solutions. This puts medical billing and coding experts on the task of ensuring that all claims are filed according to the insurance company’s compliance standards. Our highly trained experts use experienced eyes to scrub every claim to ensure its accuracy and compliance with each insurance payer’s preferred methods of transmission.
