The term “Medically Necessary” plays a critical role in a lot of claims submitted to insurance companies, payer agencies, and public health institutions. Medically Necessary is broadly defined as “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

Medical Necessity Defined For ABA Therapy Service

This large definition can be applied to medical healthcare services, diagnostics, and even mental healthcare therapy. In this light ABA therapy is often considered to be “Medically Necessary” for things like developing effective treatment plans and outcomes for individuals with Autism Spectrum Disorder.

Though not all, private insurance companies or plans treat ABA therapy the same way. Some of these payers and public health institutions require the services they cover, approve, and reimburse to be extensively documented. This might include requiring providers to present this information in advance of treatment for prior authorization. Failing to do so, might result in a claim rejection or denial.

A few private insurance companies also require a post-service review. This often comes as a request for medical documentation after services are provided in a standard review or a request for an audit.

When you get right down to it, a lot of payer institutions have their own unique medical necessity standards for how they treat ABA therapy. Some employ a combination of external guidelines, along with state, local, and federal laws.

A lot of the commonly used external guidelines are taken from the InterQual Behavioral Health Medical Necessity Criteria or the MCG Health Behavioral Health Care Guidelines. This means that most providers need to be knowledgeable about these different requirements for documentation.

ABA therapists also need to take the time to verify the insurance policy coverage for the member. This includes a diligent review of the diagnosis and service. If these are not covered under the patient’s plan, they will be denied, even if all of the documentation is perfectly composed.

It’s also worth noting that while ABA is frequently covered for patients needing mental health care, it is not typically covered in other areas. This might include academic/educational, vocational, or recreational activities which might not be deemed to be medically necessary. Careful documentation of goals, treatment plans and intervention becomes critical for times when ABA therapy needs to take place in a school or some type of community setting, outside the clinical realm.

If a patient needs ABA therapy outside of the clinical environment, you should expect the insurance company to ask for additional information such as:

  • The patient’s demographics
  • A diagnostic evaluation that is specific to autism spectrum disorder
  • Documentation of standardized autism testing
  • An adaptive Behavior Evaluation
  • A relevant medical history
  • A copy of the prior or current treatment plan
  • Biopsychosocial information
  • Any pertinent dosage information
  • Dosage frequency and duration of service
  • Relevant information about direct therapy, case supervision, and caregiver training
  • A copy of the individualized treatment plan
  • Explanation as to why goals could not be mastered or effective by a lower level of care
  • Detailed credentials, contact information, and signature for the provider rendering provider

Additional Information That Might Be Needed

A lot of insurance companies, payers, and public health institutions keep statistics about the practices they receive frequent claims from. If your practice is continually drawing red flags for things like a lack of prior approval, coding errors, and missing documentation, it might trigger an audit request from the payer.

In a scenario like this, you might be asked to provide a significant amount of additional information. This includes things like:

  • A detailed breakdown of goals
  • Answers to questions about the treatment plan
  • The patient’s academic involvement & progress
  • Skills-based assessment information
  • The patient’s behavior intervention plan
  • Parent or guardian involvement
  • A transition plan
  • A possible discharge plan
  • Hours/units being requested and codes

The payer institution might also request information from other members of the patient’s support team. This might include:

  • Psychologists
  • Individualized Education Plan/Services
  • Teachers
  • Psychiatrists
  • Speech Pathologists or Speech Therapists
  • Anyone who is concurrently providing services
  • The Value Of Updated Credentialing

A lot of insurance payers and public health institutions verify credentials with an ABA therapist to ensure they are qualified to provide an approved level of care for their patients. Things like your education, years of experience, areas of specialty, and the local demographic demand for your services can affect the reimbursement rate they offer.

Updating your credentials every year, or whenever there’s a change in your favor, will also help maximize your payment fee schedule for the ABA services you provide to patients.

Ensuring Accurate Claims With Outsourcing

One of the best ways for an ABA therapist to ensure that their treatment plan is covered fully, at the maximum reimbursement rate for their services, can be daunting. Payer institutions might recognize ABA therapy as the gold standard for the treatment of Autism Spectrum Disorder, but they require extensive documentation to ensure that everything meets their standards for being “Medically Necessary.”

When you work with a third-party medical billing specialist like Operant Billing Solutions, you can trust that our highly trained experts are well-versed in everything you need to properly code and submit a claim to a wide range of payers. Our medical billing specialists turn a keen eye to make sure that all the necessary documentation is included with every ABA therapy claim.

Not only does this significantly reduce the risk of a claim rejection or denial, but it also helps keep your ABA practice’s revenue stream consistent. At the same time, it also reduces the number of red flags and questions your practice’s claims draw from payers and public health institutions. This can go a long way toward reducing your chances of a requested audit.

A lot of solo practitioners and small ABA therapy practices who contract Operant Billing Solutions find that outsourcing their medical billing needs leaves them with more time to serve their patients. Many even manage to add new patients to their roster. This further helps maximize their reimbursement rates for a more vigorous revenue stream.