You may know, or at least suspect, that you need a guide to insurance for ABA providers. We agree and we want to help you make billing with insurance as painless as possible. That’s why we’ve provided these 5 tips to help you start improving the way you do ABA insurance billing.
Tip #1: Make sure you understand insurance coverage as it relates to your clients and your state.
Not all insurance plans cover applied behavior analysis (ABA) therapy in the same way. One way to make sure you are eligible to receive payment for services rendered is to confirm whether your patient has health insurance and how it covers ABA therapy. As of October 1, 2019, 50 states and the District of Columbia mandate insurance coverage for ABA therapy; however, not all 50 states cover ABA therapy at a universal level.
- California, for example, requires that every health insurance policy must cover “behavioral health treatment for pervasive developmental disorder.” (Cal. Insurance Code Sec. 10144.51 and Sec.10144.52 2011 Cal. Stats., Chap.650; SB 946) Such coverage does not require that the benefits paid exceed the federal essential health benefit level under the Patient Protection and Affordable Care Act.
- California also requires ABA therapy coverage for a person of any age under the same rules that apply to other medical infirmities.
- Other states mandate a specific age limitation. In Maryland, for example, the age limit is 19; in others, like Delaware, it’s age 21.
- Florida mandates that health insurance plans cover ABA therapy but limits that coverage to $36,000 per year, subject to a $ 200,000-lifetime maximum.
- In addition to maximum age thresholds and maximum benefit limitations, insurance company policies may also restrict how long a person may receive ABA therapy treatment, restrict in-home ABA therapy, and so on.
These variations make it especially important that you know the rules as they apply in your jurisdiction. Always take things a step further and speak with your clients’ provider to verify coverage before you start a session.
Tip #2: Make sure you’re credentialed.
You have to check your clients’ coverage, but you also have to make sure your practice is recognized by the insurance company. Every insurance carrier has its own conditions and prerequisites that a therapist must meet before the company will pay for ABA therapy by that provider. The conditions include credentialing for the therapist.
Credentialing means providing documentation in support of your application for approval, such as your medical licenses, a salient overview of your education and work-life (curriculum vitae or C.V.), proof of medical malpractice insurance and its limits, a list of hospitals where you have admission privileges — to name a few. It can take about a month for the initial credentialing process to gather the necessary information and responses from schools and boards and other references. After your practice completes the initial vetting process, the insurance company will verify the sources on your application and then submit your application for approval or disapproval to a credentialing committee.
Credentialing is critical for a medical provider’s eligibility to accept payment from a third-party payor (the insurance company).
Tip #3: Become an in-network provider.
Patients covered by what’s known historically as an indemnity plan can go to any doctor they want. On the other hand, patients covered by a preferred provider organization (PPO) or a health maintenance organization (HMO) 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. Insurance plans reimburse in-network providers at a higher rate than out-of-network providers. Sometimes they won’t pay out-of-network providers, making the patient 100% responsible for the cost of services rendered.
In-network providers (physicians, hospitals, and labs) sign a contract with the health insurance carrier to provide services at a discounted rate. In return, the insurance company provides an ongoing patient stream which requires that patients use the insurance company’s preferred provider list in order to receive maximum payment. This agreement allows the health provider to spend less time searching for new patients.
Providers are selected based on education, credentialing, the size of the discounted fee the provider sets for the covered patients/insurance company, and the provider’s availability to accept new patients. After application approval, the insurance company will offer a contract to the provider. In-network providers must also agree to follow all the rules the insurance company sets.
Tip #4: Have the right system in place for filing claims (and getting paid).
Once you receive approval as a credentialed provider, you might think it a simple matter to submit invoices for services rendered. However, if you don’t have a practice management system in place that also covers billing, then claims submissions (and payments) can become a hassle.
Each insurance company has its own forms that providers must complete. Each claim form requires appropriate medical coding for the service performed and other pertinent information about the client and your practice. Therefore, you must maintain your updated familiarity with the Current Procedural Terminology (CPT) codes that apply to ABA therapy services. You must also maintain updated records on your client’s personal contact information and insurance information.
If any of the information completed on the form is in error, the company will deny the claim. Companies also have filing deadlines to which providers must adhere or the company will deny the claim.
Tip #5: Don’t ignore claim denials.
If a client’s insurance company denies your request for payment, under certain circumstances, you may appeal the decision. So, it’s important to know the appeal procedures of that particular insurance company. Generally, you may appeal if:
- you don’t know why the claim was denied;
- you received payment but it was in the wrong amount;
- you disagree with the insurance company that the patient had a disqualifying preexisting condition;
- you disagree with the insurance company’s determination that the services were not “medically necessary”;
- the company’s payment does not reflect special circumstances that required complicated medical services;
- your payment was denied because you did not obtain pre-certification but you had determined special medical conditions precluded pre-certification.
Alternatively, you can secure services that will review and fix claim denials for you (and even lower the occurrence of denials in the future).
A few final thoughts for a successful relationship with insurance companies.
Bear the following suggestions in mind when working with insured patients:
- Make sure you collect all co-payments and deductible amounts as required under the patient’s policy at the time of service or in weekly or monthly invoices covering those services. This is your responsibility as a provider. The insurance company will not collect those for you.
- Document the name and phone number of any insurance company staff member to whom you speak.
- Take good notes of your conversations and provide all documentation within the time frames requested.
Ready to Get a Handle on Your Billing?
CodeMetro has you covered from start to finish. We help you with contracting and credentialing and submitting claims through our practice management system. Start with a quick demo and get everything you need.