By Christan Griffin, M.Ed., BCBA, LBA
Components of Service Approval
Autism Spectrum Disorder (ASD) is classified as a developmental disorder rather than a cognitive disorder, although both diagnoses can be co-occurring in the same individual. Per NIMH, autism is classified specifically as a developmental disorder because the presentation of the symptoms are observed early in the child’s prime developmental state (NIMH, 2018). These slight differences would seem trivial for a beginner in the behavioral health field or for the newly diagnosed. However, when speaking with ABA providers, state-funded payers, or managed care organizations, the difference of one DSM-5 code versus another in a similar or related category, could be the difference between:
- Services approved or denied
- Whether the claims submitted will be reimbursed
- Compliance with funder guidelines by only providing services under approved service codes per individuals’ primary diagnosis
Why is This Important?
A common theme can be deduced when speaking with caregivers, regardless of what phase they are in with acceptance, which includes the desire to access therapeutic and medically necessary services for their child. Whether a parent of a newly diagnosed toddler or a parent of a teen navigating middle school, both have one common purpose: prompt access to behavioral health benefits, such as ABA therapy. In March 2021, the Children’s Health Advocacy Institute (CHAI) released an article highlighting the importance of behavioral therapy:
“Families must navigate a multifaceted and complicated system and overcome significant systemic barriers to obtain an ASD diagnosis or identification and related treatment services, which contributes to inequitable outcomes. These barriers are also seen by child-serving providers across disciplines that provide care for families affected by ASD, including professionals in behavioral health care…” (Current landscape, 2021, p.1).
Know the Difference
The credentialing and provider enrollment process is vital. It ensures services can continue if the patient requires and continues to meet medical necessity when it is time for the six-month authorization. Know the difference and the requirements for each process to prevent mistakes and support streamlined, clean submission of documentation. Below is a breakdown of each process:
Credentialing consists of confirming the credentials of the certified or licensed provider and thoroughly reviewing their background and assessing the provider’s validity. Obtaining credentials with an MCO will typically involve providing the following types of information (Stall, 2021).
- Education History
- Clinical Work History
- Clinical Specialties
- License Information
- Liability Insurance
- Background checks
Concerning provider enrollment, the following steps would take place (Stall, 2021):
- The provider applies to take part in a specific health insurance network.
- Once the provider is approved, they can bill for services rendered.
- During this process, the provider can expect to sign a contract and have an on-site visit completed by the payer.
Payer contracting occurs when the provider and payer negotiate reimbursement rates for the services provided. This process typically involves the following (Stall, 2021):
- Application Forms
- Business Information
- Tax, EDI, and EFT Information
- Contract Review and Forms
- Provider Data Rosters
Errors at this stage of the process could prevent the patient from accessing services for months and affect the ABA agency being reimbursed; not to mention providing services out of compliance with payer’s guidelines. Credentialing should be the agency’s first order of action for the ABA provider planned to supervise and implement the treatment plan. Errors will also increase tedious processes that require significantly more time to correct, decrease revenue, and increase overhead costs that are not reimbursable (Stall, 2021).
Increase in Denials Cause Delay in ABA Services
Denials occurred prior to COVID-19, but there has been an increasing trend of the number of services being denied since the pandemic began. An insight article by Medical Group Management Association released in December 2021 shared the following:
Credentialing can significantly contribute to claim denials, as reflected in an Aug. 24, 2021 MGMA Stat poll in which more than half of medical practices reported denials related to provider credentialing increased in 2021. In that poll, practices noted that they had experienced denials for numerous reasons, including:
- Prolonged delays in processing new provider applications
- Lack of communication from payers to medical practices
- Frequently changing and varying requirements
- Closed networks/issues with new plans
- Outright discrepancies
It is no wonder why RCM KPI services catapulted into the limelight in the past two years. Automated software is desperately needed to improve access to care, and not only for the rural areas anymore. The pandemic has driven up the need for innovative technology with automation and formulas to help ensure correct information is entered the first time by prepopulating information. Initially, billing management in-home gave the impression of saving money due to operating costs – and it is understandable why. However, human error, incomplete forms, and expired credentials can set back the process by weeks and even months. Automated systems are developed to catch and prevent these types of errors, as well as transfer vital information quickly through HIPAA compliant servers. Therapy Brands’ mission is to support behavioral health agencies with complex administrative processes, which increase efficiency across the organization, allow ABA providers to spend more time on clinical based activities with patients, increase the number of patients being served, and provide extra time to spend with family to support a healthy work/life balance.
Download Your Free Credentialing, Contracting, and RCM White Paper
Autism Spectrum Disorder. National Institute of Mental Health (NIMH). Retrieved 21 December 2021, from https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd#part_2283.
Community Mental Health CORE (Collaboration, Outreach, Research, Equity)
Child Health Advocacy Institute, Children’s National Hospital. (2021) Current Landscape of Behavioral Health Services for Children with Autism Spectrum Disorder Insured by Medicaid in Washington, D.C. [Ebook] (pp.2-43). Washington, D.C. Retrieved from file:///Users/christy_macpro/Downloads/Current%20Landscape%20of%20Behavioral%20Health%20Services%20for%20Children%20with%20ASD%202021%20(2).pdf
Stall, D., Brinkman, M., & Padula, N. (2021). Billing 101: Credentialing, Contracting and Understanding Eligibility by Therapy Brands. Presentation, webinar.