Every ABA therapy practice should have some sort of insurance guide. While there isn’t technically such a guide in print, there are some key industry insights and tips that will help streamline the process in a way that will help save your ABA practice time and money.
Stay Informed On Each Patient’s Insurance Coverage
As an ABA therapist, you need to always be mindful that not all insurance plans cover applied behavior analysis therapy in the same way. With each new patient, you need to make sure you are eligible to receive payment for services rendered under the terms of their policy. This should become a standard part of all new patient intake processes.
Then also make sure that their coverage is in line with state regulations in your area. This can be an issue in some areas where state borders are closely shared. Different states such as California, Maryland, and Delaware have age requirements that might apply. Whereas in other states like Florida, there might be coverage limits for the cost of services rendered in a given calendar year or the cost of lifetime services rendered. So, make sure you are well aware of your state’s regulations regarding ABA coverage requirements as well as any other nearby states where you might draw new patients from.
Make Sure Your Practice Is Credentialed With All Major Insurance Carriers
While you are checking a new patient’s coverage, you should also take steps to make sure that your ABA therapy practice is recognized by the insurance company. This process of “Credentialing” is unique to each insurance carrier, and most have their own conditions or some type of prerequisites that a therapist must meet before the company will pay for ABA therapy by that provider.
Credentialing essentially means that you are required to offer up specific documentation that supports your application to render services. This typically includes things like your pertinent medical licenses, a salient overview of your education as well as your work file or C.V. Most insurance companies require proof of medical malpractice insurance including its limits, as well as a list of hospitals where you have admission privileges as part of their credentialing process.
In some instances the credentialing process, submission, and approval can take up to a month to fully complete. Even after your practice vets your information, the insurance company will likely also want to verify the sources on your application and then submit your application for approval or disapproval to a credentialing committee.
This is not the sort of delay that you want to deal with when you are taking in a new patient, who needs access to your ABA therapy services as soon as possible. So, taking a proactive approach to credentialing with major insurance providers will go a long way toward helping you streamline new patient intake. While you might end up spending extra time at first, it will pay for itself in time saved later on.
Become Affiliated As An In-Network Provider
A lot of patients are covered by an indemnity plan which allows them to go to any doctor or therapist that they want. Though some patients are covered by a “Preferred Provider Organization,” which is also known as a PPO. Others might belong to a “Health Maintenance Organization” known as an HMO. Under these PPO and HMO policies, the patient must receive their health insurance from a preferred provider or the HMO’s staff. A preferred provider is also known as a provider that operates in-network.
Many insurance plans reimburse in-network providers at a higher rate than out-of-network providers. There are even some that strictly won’t pay out-of-network providers, which ultimately make the patient 100% responsible for the cost of services rendered.
For your ABA therapy practice to become recognized as an In-Network Provider, you will need to sign a legally binding contract with the health insurance carrier to provide services at a negotiated discounted rate. What you get in return is the insurance company providing an ongoing patient stream by including you on that insurance company’s preferred provider list.
This sort of trade-off agreement allows you as the provider to spend less time searching for new patients. It also translates to a more consistent revenue stream by significantly reducing the risk of claim rejections and claim denials.
How Are In-Network Providers Selected By PPOs & HMOs?
Insurance companies approve providers based on education, as well as credentialing, the size of the discounted fee the provider sets for the covered patients, and your general availability to accept new patients.
Once your provider application has been approved the insurance company will offer a contract to you to become an in-network provider. Though you need to read the fine print with these contracts to make sure that you are accepting new clients and filing claims according to the insurance company’s covenant of rules.
Develop & Maintain An Organized System For Submitting Claims
Claim submissions are not a place for creativity. After you receive approval as a credentialed provider, you might think it a simple matter to submit invoices for services rendered. Yet if you don’t have a practice management system in place that also covers billing, then claims submissions you will still face delays, as well as increased risk of claim rejections and denials.
Every insurance company has its own in-house forms that providers must complete as part of the claim submission process. Each of these claim forms is required to use the appropriate medical coding for the service rendered as well as all other pertinent information about the client. This also includes key information about your practice.
This makes it absolutely critical for your ABA practice to maintain up-to-date familiarity with the Current Procedural Terminology (CPT) codes that apply to any and all ABA therapy services. Your practice also needs to maintain updated records on each patient’s personal contact information and insurance information.
Be Prompt In Dealing With Claim Denials.
Even the slightest error or omission of information on a claim form can lead to claim denial. If you have a claim for service denied, be proactive about reaching out to understand why. If it is a matter of a missing data field, be sure to correct it as soon as possible and resubmit the form to the insurance company or public health institution.
Most have regulations that set a time limit on how long you can resubmit a claim after it has been denied. This can also be a factor if there is a prolonged amount of time between when you submit the corrected claim information and the original date of the service rendered.