doctor in scrubs working at their desk

Best Practices for Determining Medical Necessity in Autism/ABA Treatment (Video)

This article is based on our recent webinar, Entrepreneurship in ABA: Best Practices for Determining Medical Necessity in Autism/ABA Treatment - Part 3, presented by Dr. Diana Davis-Wilson, DBH, LBA, BCBA.

Dr. Davis-Wilson is a licensed behavior analyst, with several years of experience providing consultation and training to families, school districts, and organizational personnel nationwide.

She holds a Doctorate of Behavior Health with an emphasis on integrated health care management and is currently the Chief Executive Advisor for Aspen Behavioral Consulting.

On-Demand replay of our webinar

If you are interested in learning more about how to break into, succeed, or grow as an ABA provider, you can sign up for our monthly webinar series, Entrepreneurship in ABA.

Medical necessity is a contractual concept related to healthcare coverage and activities that must be justified as reasonable, necessary, and appropriate, based on evidence-based standards of care.

The majority of health care contracts often include agreements which declare that a plan will provide coverage only for services that are thought to be reasonable and necessary.

Determining this will be up to the discretion of health plans, and in accordance with applicable law.

But how do we determine medical necessity in Autism and or ABA treatment?

Having reviewed samples of treatment plans given by health providers from across the nation, the most obvious and glaring concern is often consistency in documentation and in justification of medical necessity.

Also of notable interest is that many record reviews not only have inconsistency across certain regions of the nation or certain providers but also demonstrates inconsistencies across the documentation within the individual work of the behavior analysts that authored the plans.

What would be appropriate for medical necessity justification?

When consistency and documentation is among the major hindrances, what would it look like for health plans?

How hard would this be from an administrative perspective or a cost-effectiveness analysis?

Perhaps, a tool designed to bridge the language barriers between the clinician and the health plan could present some sort of consistency or standardization in the treatment planning process and assist clinicians in crafting medical necessity justification.

This way, all parties are speaking the same language.

Advancing The Medical Necessity of ABA

In order to continue the necessary conversations related to the medical necessity of autism treatment, the development of a medical necessity review tool may lend guidance for clinicians toward consistency in considerations of medical necessity justification.

In addition to serving as a training and quality assurance tool, the tool may also highlight the limitations pertaining to the research gaps and with that, empower and encourage others to develop research that can continue to advance the medical necessity justification of ABA treatment across a wide range of populations.

While setting a standard based on research for a specific hour amount (i.e. 22 hours for one client, 18 hours for another) may be ideal, it is unlikely that we are ever going to have that level of precision for reasons that would go against our own science.

In essence, we are always going to have to be able to calibrate our clinical decisions as necessary depending on the conditions that are going on in the environment.

We have to be able to make rapid changes based on frequent data analysis.

In fact, our own research method design allows for us to do just that which also makes dosage ranges a more realistic expectation due to the ability for synthesized research to provide clinical rationale anchors.

All the while, it is imperative to keep in mind with medical necessity is that there's not just one perspective to ABA in autism treatment and that in order for us to most effectively advocate both in public policy and then on a smaller level for individual plans with individual treatment plans with the health plan is that we really have to understand the patient and health plan perspective.

Additionally, the guidance of the tool would intend to demonstrate the limitations and best available evidence.

For example, if there is a discrepancy between the clinician’s recommendation and what the tool is saying, it does not mean that the clinician’s recommendation is wrong.

Rather, it is a suggestion that the research support base to support the clinician’s recommendation may be, different or limited, or may even need additional justification for that particular individualized case.

In other words, the best available evidence may be more difficult to define.

Therefore, treatment planning may need more precision.

Purpose of the Tool

The main advocacy of creating a tool for guiding the determination of medical necessity for ABA treatment is to address complex language barriers amongst key stakeholders and organizing various perspectives.

This will also encompass the following:

Education - Integrate the research in a fashion that educates those that provide support for the study and assist in a decision-making process for and articulated by clinicians.
Consistency - Provide documentation standardization and considerations for clinical report writing.
Training - Decision path tool for future clinicians.
Research - To shed light on research efforts that need to be established or strengthened – i.e. populations, age, diagnosis, etc.

However, this tool is not intended to replace the required clinical calibration necessary for individualized treatment planning.

Variations in the tool guidance is intended to demonstrate limitations in “best available evidence” and help establish direction in our advocacy efforts.

This is also not to guide funder or legal mandates on dosage or utilization requirements.

Key Features

• Produces a suggested dosage range or guideline based on best supporting synthesized evidence
• Provides a summary of the treatment plan components
• Provides a quality management training opportunity for supervisors or organization

teacher sitting with boy looking at a globe

10 Things You Should Know Before Starting an ABA Practice

This article is based on our recent webinar, Entrepreneurship in ABA: Top 10 Things I Wish I Knew Before Starting an ABA Practice, presented by Molly OlaMolly Ola Pinney, Founder/CEO of Global Autism Project Pinney, Founder/CEO of Global Autism Project.

If you are interested in learning more about how to break into, succeed, or grow as an ABA provider, you can sign up for our monthly webinar series, Entrepreneurship in ABA.

Starting a new Applied Behavioral Analysis (ABA) practice can be an exciting endeavor.

However, it can be also challenging if you don’t know where to start or how to compete against other practices that are already up and running.

Most practitioners undoubtedly start out with the idea to help others, but the reality is that many business owners fail for reasons including their inability to develop business know-how, a strong financial model, and an adequate sustainability plan.

To succeed in this emerging industry, you must learn it to understand the business side of your practice just as well as the clinical side.

The different facets can be overwhelming if you’re not already familiar, which is why we thought this would be a helpful topic to discuss.

In our recent webinar Entrepreneurship in ABA: Top 10 Things I Wish I Knew Before Starting an ABA Practice, Ola Pinney shares lessons from her own experiences and offers insight into the top things every ABA provider should consider to protect the sustainability and scalability of their business.

“Our organization has spent over a decade training businesses providing services across the globe, and I can’t wait to finally share what we’ve learned with you!” – Molly Ola Pinney

Here are a few tips to take away:

1.) Have Focus In Your Business

You should have a really compelling reason for switching gears in your practice.

A decision-making matrix can help you look at the different things you should focus on like time, costs and staff buy-in.

You should also be mindful of your messaging, marketing efforts and strategic efforts to support your bottom line.

2.) Learn More About The Numbers In Your Business

Even if you have an accountant, it is important that you understand cash flow and can plan for the future.

Some business owners tend to make a budget at the beginning of the year and then randomly check it throughout the year.

A regular budget analysis and plan for cash flow will help you note how money is coming in and going out so that you scale and spend appropriately.

Investments should also have a return.

3.) Develop A Crystal Clear Mission

The way that your business is going to attract people is by helping others understand and support your mission.

Ask yourself if you know where you’re headed and how you’ll get there.

According to Ola Pinney, “The how doesn’t matter nearly as much as the when, where and why.” When you’ve figured out your mission, you’ll want to figure out your why.

If you don’t yet have a mission, sit down with your team and write one down.

Then figure out your verticals and your people.

4.) Make Good Staffing Choices

Having a strong vision or mission will attract people who are there because they want to be.

You need specific expectations, guidelines and go-to policies.

You should leave no stone unturned when hiring, which may include creating an employee handbook (if you don’t already have one) and running guidelines and policies by your lawyer.

Think about the culture of your organization and what’s important to you and the people who work with you.

Weekly reports and regular meetings are amazing tools you can use once you have the right team.

You should also have a clear disciplinary process in place and never forget to hire slow and fire fast.

5.) Make Sure You Have A Strong Digital Presence

Does your company show up on multiple platforms?

Are you using social media platforms and ads appropriately?

Remember that your image should match your voice, your people should see themselves in your practice’s page and your visual identity should be clear, simple and inspiring.

Remember that you are connected to your company, so your personal image matters too.

6.) Determine Whether Your Company Is Scalable

In order to make your business scalable, you need strong processes.

Documenting processes allow you to plug in to them later and keep everything in one place so everyone knows where to go.

You should also think about your team and who you need on your team to move forward.

7.) Time Management Is Key

Even if you don’t think you have enough hours in the day, you do.

There are also enough hours in the day to take care of your body, mind and spirit.

“A good way to manage your time is to block and tackle,” says Ola Pinney.

Think about repetitive tasks and ways to leverage your time.

You should also delegate more tasks to others who can perform them.

8.) Change Your Mindset

In order to get a handle on the things you’d like to do, you need to change your time.

Try on the idea that you are the strong leader of your business and then figure out if you’re the roadblock to your own success.

9.) Be Consistent With Your Marketing

“One of the best ways to get the word out about what you do, is by talking about what you do,” says Ola Pinney.

Effective marketing requires a commitment to growth and a voice that people trust and want to hear more from.

Listening to and implementing best practices also help to make your marketing efforts more sustainable.

10.) Go To The Source

There is a lot that you can learn from others, including competitors/colleagues within the ABA field.

Make it a point to network and have a casual conversation.

These are just a few tips of the many things you should keep in mind as an ABA provider.

Another tip would be to have a practice management platform in place to streamline your processes and promote scalability while still ensuring client success.

Our one-stop-shop platform offers Billing services, Clinical tools, and Practice Management tools along with RBT Training, VB-MAPP licenses, and more than 1500 resources/materials as curriculum pieces.

Schedule a demo today at your convenience!

little boy on a playground crying

Liability Insurance Basics & Current Claim Trends in ABA Therapy

This piece is based on our recent webinar presented by Daniel Law, ARM, CRIS and President of Liberty San Jose of The Liberty Company Insurance Brokers.

You can sign up for the monthly webinar series, Entrepreneurship in ABA, mailing list here.

One of the most important business principles is to have an effective liability insurance policy in place to not only protect your business, but also yourself.

Insurance may be required for certain transactions and are usually a pre-requisite for the following:

  • During the process of obtaining funds
  • When applying in a school district/Regional center
  • From Easter Seals/BHPN
  • When trying to lease an apartment, a landlord may ask insurance from you

On the other hand, in order to be eligible for insurance, one must know the following:

  • Limits and type of coverage is within the range $1m-$3m
  • Indemnification
  • Additional insurance
  • Waiver of subrogation

ABA providers face unique risks such as:

  • Inherent Risks with Autism
  • Professional Exposure
  • Dangers to Employees
  • In-Home, School-Based, Clinic
  • Hiring and Retention
  • Regulation (Licensing, Funding Source, Authorizer)

For ABA therapy, the liability coverages are as follows:

Professional Liability

This is covered by a wide range of aspects such as in professional services fees incurred, a wrongful act by an employee or even for some circumstances the government mandates that or from regulatory standards.

They may be liable as well to those who are additionally insured, who are already insured or those who have a waiver of subrogation.

General Liability

This covers bodily injury, property damage, personal injury and even advertising injury.

The coverage may be divided into 3rd party coverage, the number of occurrences, limits and deductibles.

The liability will also differ when there is additional insurance, has waiver of subrogation and to those with common exclusion.


This item covers the vicarious liability, exclusions, and limits with the first item being the most concentrated one.

Vicarious liability will be in effect if the person being insured is known, there is an innocent party defense, and what items will be/should be covered.

Automobile Liability

This item covers the hired automotive, non-owned automotive liability, and physical damage liability.

Physical damage is determined by which a person involved is insured/not insured, the application/coverage of the liability, and the determining of who can be able to drive and who cannot.

Cyber Liability

This is a liability policy that covers a data breach or compromised personal information of a client.

It can be covered by the consideration of HIPAA concerns, how much the coverage is and other options.

In this manner, the regulatory trends are appropriate to be considered.

The WCIRB – NCCI should be taken into account regarding Workers' Compensation changes while for funding sources, the increased requirements and increased scrutiny should be considered as well.

Lastly, for regulatory trends, it is important that accreditation, state licensing, and inspections are to be considered as well.

In the aspect of claim trends, the following should have attention:

Independent contractors

RBT cannot be an IC or else it would be Mis-classification.

In the event the IC wants to have the medical bills paid, the action over claims must be understood. In terms of work comp issues, one must consider looking into those who are not paying a premium.

Cyber/Data Breach

In this type of claim, several items should be assumed to be claimed:

  • HIPAA Allegations/Violations
  • The costs involved incurred by the breach
  • If the attacker claims for ransom
  • The liability on who owns the records

These are some of the items that may be claimed in the event of a Cyber/Data Breach.

According to Bloomberg, health data breaches can cost more than $400 per patient and have an average claim trend of ~3m per year.

This is due to the fact that Phishing and social engineering have been the major drivers of cyber events.

Employment Practices Liability

Possible claim items include misclassification, wrongful termination of an employee and failure to pay appropriate wages and incidentals such as overtime, drive-time, and breaks.

Workers’ Compensation

This claim item includes worker vs. contractor claim disputes, classification systems, and even the origins/causes of the injuries.

Injury to Children

This is one of the most sensitive items mainly due to the fact that children are involved in this situation.

Claims could come from the clinical setting, community outings (i.e. injuries from accidents on the event), and even child abuse/molestation.

Indemnity and Defense

This claim item includes the item about contracts (i.e. a school was being sued by its employee after being injured), how the claim works and what are the items seen in certain situations.

Rethink Behavioral Health provides an intuitive and comprehensive solution to scale your ABA business and ensure client success.

Our one-stop-shop platform is HIPAA compliant and offers both Clinical and Practice Management tools along with RBT Training, VB-MAPP licenses, and more than 1500 resources/materials as curriculum pieces.

Schedule a demo today at your convenience!

a diverse group meeting in a conference room

10 Tips for Motivating and Retaining Staff

This piece is based on our recent webinar presented by Erin Mayberry, MS, BCBA, LBA and current Professional Services Consultant for Rethink Behavioral Health.

You can sign up for the monthly webinar series, Entrepreneurship in ABA, mailing list here.

Have you ever felt burnout at some point in your employment?

In one way or another, each one of us has experienced a certain type of stress that was induced at work or because of work.

In Applied Behavior Analysis (ABA), staff burnout is an essential item that needs to be monitored as it can lead to high turnover and disrupt consumer care.

On average, a behavioral therapist costs an estimated $5,000 upon leaving the company, not including the money spent on recruiting, onboarding, training, etc.

Let’s find out more about the most common work stressors:

According to Schulz, Greenley & Brown (first published in 1995)1, the most common stressors are the following:

  • Organizational Context (size of the company, task ownership, staff compensation, leadership style)
  • Work Satisfaction (nature of work, workload, work routine)
  • Client Severity (mental illness, psychiatric tendencies, developmental disabilities)
  • Work Environment (lack of job clarity, difference in company/organizational goals)
  • Staff Characteristics (Role tenure, age, staff education)
  • Organization/Management Process (Organization culture, influences on leadership, lack of social support)

In addition, common work stressors according to Waters (1999)2 are as follows:

  • Relationships with Coworkers and Supervisors (unsupportive to collaborations)
  • Effort vs Reward (felt undervalued, overloaded with work)
  • Lack of Influence on Decision Making and Outcomes (one’s opinion is not valued or is overlooked)

A literature review of burnout research was conducted by Bakker & Costa3 in 2014 which focuses on loss cycles and loss-gain cycles of chronic burnout.

In the research, the loss cycle consists of the following:

  • Job demands are associated with physiological and psychological costs. This includes fatigue/loss of sleep and increased heart rate which may then lead to physical and mental exhaustion
  • Daily exhaustion has the tendency to impact one’s work performance, which may then lead to employee ineffectiveness

In the case of the loss-gain cycle, the following are considered:

  • Encouragement of personal growth by providing better work opportunities
  • Availability of job resources and versatility

So how should we mitigate employees experiencing staff burnout?

Here are some of the most effective ways to prevent staff from experiencing burnout in the workplace:

Set Clear Expectations

As leaders, being transparent is a key trait in gaining trust from your staff. The same is true with setting expectations for them.

You have to ensure that expectations are clear and defined in measurable/observable terms.

If there are expectations that cannot be met for some reason, there should be a contingency plan in place.

Provide Effective Training

Onboarding new staff is time-consuming and often expensive.

With that being said, it is most ideal to train them properly rather than being thrown into a new role with no formal training at all.

A structured training method such as behavioral skills training or a peer training program can truly help in achieving positive, lasting results.

Not just onboarding, professional development can increase employee morale, performance, and treatment.

Provide Frequent Feedback

Let’s face it – an employee will not know what he/she is doing is right if no one tells him/her about it.

Make sure to provide feedback to your staff regarding their performance.

Balance corrective feedback with positive feedback, and try to only provide positive feedback occasionally.

Utilize Peers

The best way to encourage staff, specifically if they are performing well, is by telling them that they are doing well, which doesn’t always have to come from leadership.

Colleagues/peers can also help you provide feedback to their coworkers.

This can be achieved through shout outs, peer training and observation, and feedback in the moment.

Establish Individualized Goals

Personalized goals are effective because staff have more buy-in and accountability when they are able to help create the goals they will be working toward.

Every staff brings a unique set of skills and characteristics to the job, so it is important to recognize that each staff person may need support in different aspects of their job performance.

Use Preference Assessments

Not everyone likes the same thing, thus diversity should always be one of the top priorities as a leader.

Staff bonuses may not be too enticing for some people, as they prefer more time off rather than more money.

In this case, it is always a must to practice avoiding assumptions, but rather be open to opinions of the whole staff.

Provide Incentives for Performance

Once you know your staff’s preferences, you may use them to provide performance incentives when they achieve the goal that has been set for them.

This may include money, additional paid time off, or anything else the employee may value.

Establish a Supportive Organizational Structure

If there is a supportive organizational structure, staff are more likely to work together.

A supportive organizational structure encourages open communication, respect across all levels of employment, and establishes clear goals and visions.

Encourage Self-Monitoring

By letting your staff measure their own performance, you have the opportunity to encourage staff to create goals for themselves and personally evaluate their progress toward that goal.

This is a great way for staff to have immediate feedback when leadership isn’t always available to provide feedback in the moment.

Model the Behavior You Want to Increase

The mentality “Do as I say, not as I do” is ineffective. The more effective way to lead is by example. Model behaviors you want staff to imitate.

You can also encourage staff to be models for their peers. Some staff learn best by observing a competent colleague demonstrate a skill first.

By including some or all of these strategies in the workplace, you can reduce the stress and burnout staff may feel on the job.

Not only will staff be more supported, their overall job performance may improve as well which can lead to increased client happiness.

Two simple, low-cost methods to get you started (or keep you on the right track) is providing professional development such as Registered Behavior Technician (RBT) training and equipping your team with the necessary, mobile-friendly tools to make their on-the-go job easier.

Rethink Behavioral Health provides an intuitive and comprehensive solution to scale your ABA business and ensure client success.

Our one-stop-shop platform offers both Clinical and Practice Management tools along with RBT Training, VB-MAPP licenses, and more than 1500 resources/materials as curriculum pieces.

Schedule a demo today at your convenience!


  1. Schulz, R., Greenley, J.R., & Brown, R. (1995). Organization, management, and client effects on staff burnout. Journal of Health and Social Behavior, 34, 333-345
  2. Waters, J.E. (1999). The impact of work resources on job stress among correctional treatment staff. Journal of Addictions and Offender Counseling, 20, 26-34
  3. Bakker, A.B. & Costa, P.L. (2014). Chronic job burnout and daily functioning: a theoretical analysis. Burnout Research (1), 112-119.

Businesspeople looking at paper charts and a macbook

New Category 1 CPT Codes for Applied Behavior Analysis (ABA) Services

rethink-vbmapp-promo Category 1 CPT Codes

Anthony Porcelli, Manager of Billing Services for Rethink Behavioral Health, had the pleasure of attending Dr. Wayne Fisher’s workshop on the new Category 1 CPT Codes for ABA Services, which will be effective January 1, 2019.

I split the workshop into 3 sections:

  1. Interpreting the new Category 1 CPT Codes
  2. Suggestions to help valuate the codes when negotiating rates with payers
  3. The work was undertaken to get the new Category 1 CPT Codes accepted by the American Medical Association (AMA)

The two great advantages I see with the new codes are that they are broken up into 15-minute units to allow for more efficient billing and the ongoing codes are no longer needed.

A quick crosswalk for the more commonly used codes is listed below and more detailed descriptions can be found here.

Old Category 3 CodeNew Category 1 Code
0360T – 0361T97152
0364T – 0365T97153
0368T – 0369T97155

A key talking point of the workshop involved valuating the codes when negotiating rates with payers.

When negotiating rates it is important to demonstrate to payers the amount of work that goes into each service.

For instance, when negotiating rates for a technician appointment (0364T – 0365T) providers should mention the training that is involved between the BCBA and the tech before the appointment, the work that goes on during the actual appointment, and the interpretation of data and session notes created afterward.

To do this, Dr. Fisher suggested that providers consider each CPT Code in 3 parts:

  • Pre-Service
  • Intra-Service
  • Post-Service

Pre-Service includes everything that goes on before the appointment takes place such as training staff and writing protocols.

Intra-Service consists of the work that goes on during the actual appointment itself while Post-Service is the work that happens after a session is completed such as writing progress notes and reviewing data.

By doing this, the provider can adequately describe the full scope of work that goes into each appointment.

A further example is provided below for what goes into a Support/Technician Appointment:

0364T – 0365T

Pre-Service Work

  1. BCBA: Trains a technician to perform the service.
  2. RBT: Attends trainings with BCBA. Reviews patient medical records. Creates materials for sessions.

Intra-Service Work

  1. RBT: Works with client based on protocols created by BCBA.


  1. RBT: Writes session notes. Communicates with BCBA as needed about sessions.
  2. BCBA: Reviews/Approves session notes. Interprets data. Updates treatment plan.

Next Steps

The last piece of the workshop involved discussion on the next steps that Dr. Fisher and his group would be working on involving the new Category 1 CPT Codes.

The first order of business for the group is releasing a “Tool Kit” for providers to help valuate their services when getting ready to negotiate with payers.

Dr. Fisher and his team will also work with the AMA to address the issue of billing for both the RBT and BCBA during overlapping service times.

He believes providers should be able to bill for both services concurrently because the responsibilities of each professional during the mutual session are different.

In Summary

In summation, I believe the new codes will positively affect the ABA world and simplify the billing process.

Since the ongoing codes have been eliminated, there will be less line errors during billing, leading to faster payments and less back-and-forth interaction with the insurance companies so that providers can spend more time with their clients.

Also, since the new codes have been assigned category 1 status, I hope that payers will be more uniform with their interpretations of their use which will also make for improved efficiency in billing.

rethink-promo- Category 1 CPT Codes

From scheduling the appointment to providing resources for treatment and tracking progress to getting paid - Rethink Behavioral Health will completely support you.

No more juggling systems.

Full Features

Our complete platform features:

  • Billing & Full Revenue Cycle Management (RCM) features electronic claims submission & remittances, eligibility verification, patient statements and payments portal, financial reporting, and more!
  • Staff Training & Resources on-demand, self-paced RBT Training and access to thousands of printable resources.
  • Clinical Programming & Data Collection spend less time on administrative tasks with robust tools for assessment, treatment planning, data collection and progress reporting.
  • Advanced Scheduling Tool Easy appointment set up, view multiple staff & client schedules at once, seamless controls prevent coding and scheduling errors, capture session notes and parent signatures.

Schedule a demo today at your convenience!

filing cabinets with rows of patient medical records

Translating Medical Necessity Criteria (MNC) for ABA Providers Working with Health Plans – Part 2

The live webinar for part 3 of our Medical Necessity Criteria Series will take place on Thursday, June 20th, 2019 at 1:00 PM ET.

We will also be unveiling our brand new, industry-first Medical Necessity Criteria Assessment Tool for ABA Services!

Be one of the first to see it in action by attending the webinar.

Register now!

This piece is based on our recent webinar presented by Dr. Diana Davis-Wilson, DBH, LBA, BCBA, who is a licensed behavior analyst, with several years of experience providing consultation and training to families, school districts, and organizational personnel nationwide.

She holds a Doctorate of Behavior Health with an emphasis on integrated health care management and is currently the Chief Executive Advisor for Aspen Behavioral Consulting.

Part one can be found here.

You can sign up for the monthly webinar series, Entrepreneurship in ABAmailing list here.

As clinicians, Applied Behavior Analysis (ABA) providers seek to improve the lives of their patients by offering treatments that are both beneficial and medically necessary.

Factors To ConsiderMagnifying Glass with words

However, the needs of patients are just one of the many factors that need to be considered in health care.

There are also the needs of health plans to consider.

This is usually what ABA providers refer to as the preauthorization process where providers create treatment plans, follow standards, and send their treatment plans to health plans.

Throughout this process, health plans analyze these treatment plans to determine whether they satisfy medical necessity criteria.

Health plans are also obligated to consider medical necessity as a legal concept that follows and adheres to specific guidelines and coverage policies.

Some clinicians don’t factor this perspective into their treatment plans and as a result, struggle to comprehend what they should deliver to health plans.

In a recent Rethink Behavioral Health webinar, Dr. Diana Davis-Wilson, the Chief Executive Advisor for Aspen Behavioral Consulting in Arizona, outlined a few ways ABA providers can navigate the world of health care and “learn the language of health plans”.

The First Step

The first step, she says, is to understand how medical necessity is viewed by clinicians, health plans, and legal entities.

“When it’s unclear as to what medical necessity is or when we don’t have the data to support the typical avenues for developing medical necessity, it becomes challenging for us to present our cases to health plans,” says Davis-Wilson

Health plans are usually responsible for large populations and must make their decisions based on the interests of the majority.

This is often unique to ABA providers, who commonly look at priorities and patient care from an individual scope.

When an individual purchases a health plan, the policies are driven by many things; one of which is the population itself and the majority.

Therefore, a health plan’s job is to develop guidelines and coverage policies specific to a variety of different components outside of the individual lens.

Additional Considerations

Considerations to coverage policies include an intensive review of available documentation pertaining to the following indicators:

  • Disease burden
  • Public or provider interest
  • Controversy
  • Variation in care
  • Cost
  • Quality
  • Effectiveness of research
  • Potential impact to the entire population

To the untrained ABA provider’s eye, these factors may not have a significant impact.

But from the perspective of a health plan, decreasing disease burden, reducing long-term costs and improving the quality of care and the effectiveness of research is a benefit to a majority of individuals with health plans, not just singular patients.

When ABA providers fail to realize this, medical necessity reviews can become problematic for them and health plans.

ABA providers can also experience a breakdown in communication with health plans that must satisfy the needs for a majority within populations they serve.

Primary Goals

But at the very heart of the matter, health care will always have three main goals.

“This is better known as the triple aim”, says Davis-Wilson, and provides three objectives:

  • To improve patient care and the patient experience
  • To improve the health of populations by aiming for continuous improvement to the quality of care
  • To reduce the future per capita cost of health care by allowing individuals to obtain preventive services and care prior to the presence or discovery of certain illnesses and diseases

So where does medical necessity come in, and how can we translate it into a language that we understand?

According to Davis-Wilson, medical necessity means that the services an ABA provider carries out is for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms.

It is expected to be in accordance with the accepted standards of practice and should be clinically appropriate, efficient and cost-effective.

Measuring progress is an essential component as to whether treatment is considered efficient and cost-effective. Most plans seek to reduce the duplication of services and prevent contradictions that may be costly.

Health plans are also committed to monitoring client progress individually and as a whole for populations, thus moving them closer to their goal of reducing the future per capita cost of health care.

In essence, the more ABA providers learn to think of the whole as a sum of the individual parts, the better they will be equipped to create treatment plans and satisfy criteria in a way that health plans can understand.

Legal Components

The legal aspect of what health plans require is also very rarely discussed but plays an essential role in how health plans view medical necessity.

Many health care contracts include agreements that state that a plan will provide coverage only for services that are deemed reasonable and necessary, which is up to the discretion of health plans.

This also means that the progress an individual makes over the course of a treatment plan is more likely to be approved by health plans when it’s meaningful to overall outcomes for majorities within populations and supported by research.

When a treatment is supported by research, health plans can justify compensation for services provided and satisfy reductions and improvements to indicators such as disease burden, cost, quality, effectiveness of research and the potential impact on majorities within populations.

Yet, these are just some of the many ways ABA providers can become experts at decoding medical necessity criteria and documentation for health plans.

Learning to speak the language requires careful attention to detail and a more holistic perspective of health care in general.

Rethink Behavioral Health provides an intuitive and comprehensive solution to scale your ABA business and ensure client success.

Our one-stop-shop platform offers both Clinical and Practice Management tools along with RBT Training, VB-MAPP licenses, and more than 1500 resources/materials as curriculum pieces.

Schedule a demo today at your convenience!

patient chart folders with numbers

Documentation Requirements: The Who, What, When, Where, Why, and How of a Medical Record

This piece is based on our recent webinar presented by Sarah Schmitz, the Owner and President of Comprehensive Billing Consultants.

Sarah has over 13 years of experience in medical coding and billing and is an expert in getting you credentialed, contracted, and paid for your services quickly and properly.

You can sign up for the monthly webinar series, Entrepreneurship in ABAmailing list here.

Understanding the many facets of medical documentation can be a challenge to both patients and providers in the health care world.

On one hand, medical records are critical to the treatment of patients and on the other, they are essential to the overall organization of medical records divisions within practices across the country.

The divide between what’s expected and what’s delivered can even affect payment procedures.

So, realizing that the most valuable documentation to payers are the types that satisfy their requirements is key.

According to Sarah Schmitz, the Owner and President of Comprehensive Billing Consultants, knowing what’s expected and who provides those expectations on daily session notes and medical records should be the goal for every provider.

However, in order to master this key concept, you should first understand the basics of daily session notes.

Say goodbye to filing cabinets and take session notes on the go with Rethink.

Why do we have daily session notes?

Daily session notes exist to document all services you provide.

They give you the opportunity to go back and look at what was done and helps plan for with forward-looking care.

Consistent documentation also provides evidence regarding the assessment, treatment, and progress of services for a client.

“This is important because you will need to see where a patient started and where they’re ending up,” says Schmitz.

Documentation expands how we communicate with other service providers and ensures practitioners and all those who receive documentation are aware of any provider, client or family involvement in the daily session.

It can also serve as required evidence for insurance companies to ensure you are properly reimbursed for the services that rendered.

Here are a few benefits of daily session notes:

• It’s your legal protection for clients, the practice and practitioners
• It can be used for data and research
• It enables a facility to train and provide quality assessments and review of staff practices
• It helps you produce correct coding procedures
• It allows for optimal care of the client

Overall, it is required that session notes be permanent, legible, accurate, timely, clear, concise, complete, encompassing and truthful.

Medical records are also legally-binding and often need to be accessed or retrieved both inside and outside of a practice.

Medical necessity also almost always refers back to symptoms.

Therefore, documenting accurate diagnoses are equally important to billing policies and procedures for your practice.

Who will see these records?

Staff within and professionals outside your practice might see client medical records.

This can include administrative support staff, risk management professionals, coders and billers, insurance companies and others.

Family members could require access to session notes to facilitate the transfer of treatment documentation from one service provider to the next.

While all session notes are not required to be sent to all coordinating providers, documentation of treatment plans must be forwarded to the referring physician at each review.

When do notes need to be completed?

The best practice for daily session notes should be completed no later than seven days from the date of service.

Discharge summaries should be completed and forwarded to the referring physician within 30 days of discharge.

You should refer to state and federal requirements for any medical record storage and policies associated with your service area.

Where and how do the records need to be stored?

In order for medical records to be HIPAA compliant, a copy of all records must be backed up and stored outside the family’s home.

This includes in-home services. Medical records must also be locked away in a safe storage environment, such as a locked closet or room in an office.

If your practice chooses to use digital or electronic records, they must be double password protected and backed up regularly to a server or the cloud.

In the event that corrections need to be made to medical documentation, be aware that you cannot delete or edit items or words.

You can, however, make edits with a single line drawn through notes. All changes must be initialed and dated.

The original author should only make corrections, with supervisors serving as an exception to this rule.

Ultimately Schmitz says that the golden rule for medical records is “If it’s not documented, it didn’t happen.”

So remember to be smart about meeting requirements and creating documentation that works for your patients, staff, and payers.

Rethink's Practice Management

Rethink’s practice management makes session documentation compliance a breeze.

The customizable templates ensure that each note contains all the required information, and does the dirty work for you by pre-filling information such as the client’s name, staff name, session date/time/duration, and even inserts a summary of the clinical data collected.

Our customizable workflows enable you to ensure that the staff member completes the note before the session gets marked as completed and billed.

Finally, a PDF copy of every session note is automatically backed up to each client’s record, giving you peace of mind during an insurance audit.

Schedule a demo today at your convenience!

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For just $10 per staff member, you will receive RBT Training, Parent Training, and unlimited access to our Printable Resource Library!

You’ll also receive a $1,200 credit to cover the implementation fee if you decide to explore our clinical and/or scheduling tools. Take advantage now!

Hurry, this deal ends August 1st, 2018.

manilla folders with medical information

Navigating Insurance: Unlocking the Denials & Appeals Process

This piece is based on our recent webinar, Navigating Insurance: Unlocking the Denials & Appeals Process, presented by Emily Roche, Director of Services at ABA Therapy Billing and Insurance Services.

Emily brings a range of experience in working with ABA providers and insurance companies and has navigated contracting, appeals, and negotiations across multiple payers and states.

You can sign up for the monthly webinar series, Entrepreneurship in ABAmailing list here.


For Applied Behavior Analysis (ABA) providers, maintaining a healthy revenue stream is one of the most essential functions.

Doing so helps ABA providers keep up with organizational costs, staffing and the resources necessary to run a successful practice.

However, it is not uncommon for some ABA providers to become fraught about the complexities that surround the billing and claims process.

For some providers, fear of denial can lead to avoidance of pushy insurance companies looking to negotiate.

For others, fears can simply be rooted in an inability to navigate the appeals process when an insurance company issues a denial.

According to Emily Roche, “accurate billing can result in 90 percent of claims paid.”

In order to collect the other 10 percent, ABA providers must learn to not only track issues, but resolve errors and overcome fears of appeals by developing a deeper understanding of how to navigate the claim denials and appeals process.

The first step for ABA providers is to understand two common types of appeals:

Clinical and Medical Necessity

This type of appeal issue occurs at the time an ABA provider tries to request authorization when insurance companies may try to immediately deny authorization, reduce the number of hours requested or attempt to dictate service locations, goals, parent training or impose other restrictions.

Billing and Claims Processing

This type of denial or appeal issue occurs when a claim is sent in for processing or when an ABA provider reviews payments or Explanations of Benefits statements.

Roche says it is important to understand that insurance plans cannot dictate:

  • Service location
  • Parent training
  • Goals that relate to services
  • Timeline for reducing hours or phasing out services
  • Treatment bases on age threshold or years of ABA treatment

At the billing stage, it is equally important for ABA providers to be able to distinguish between different types of errors.

In order to do this, providers should carefully review Explanation of Benefits statements and get to the root cause of anything that has been paid incorrectly or denied.

Insurance Tips for ABA Providers

In order to help with both of these common issues, Emily offers several tips for ABA providers when working with insurance:

1. File claims in a timely fashion and pay attention to appeals deadlines. Be sure to also save all documentation if faxing or mailing claims.

2. Understand laws like the Medical Health Parity and Addiction Equity Act, which exists to protect patients, so you know when to file an appeal or push back on insurance companies.

3. Prevent the need for corrected claims or issues that grow into denials or appeals by addressing clinic-side errors.

4. Train others on how to handle peer reviews and calls with insurance companies.

5. Include the recommended number of hours at the start of services. If a request is made to reduce hours due to schedule conflicts, highlight the reason for the reduction and include the length of time hours will be reduced below the recommended number.

6. Prepare to highlight cases with a significant need or effects that occurred in cases when an issue was left untreated or under-treated.

7. Avoid sounding “too academic” when explaining the reason why a patient needs a particular service.

8. If an insurance company tries to deny a full authorization or reduce hours at the authorization phase, ask for a peer or secondary review after the initial review or phone call. If you go through a secondary review and receive a denial, be sure that the reviewer issues a denial for the difference in hours.

9. If an insurance company authorizes payment for a percentage of recommended hours, the insurance company should issue an authorization for the designated hours they approve of and a denial for the hours not approved. If the insurance company issues a full denial, be sure a denial letter is issued to the provider and the parent.

10. When preparing to write an appeal, be sure to include demographic information, copies of treatment plans, notes and reports and any supporting documentation. Remember to use clear language and be concise. You should also refer to any sections of your contract that are being violated, if any.

If you encounter issues such as not receiving a denial letter at all or harsh restrictions from an insurance provider, you can file a grievance or complaint if you are a member of a network.

Remember that you can also exercise your right to consult a healthcare attorney, who will have a deeper understanding of health care laws, or opt to leave or switch your network if issues continue.

Health insurance is very complex, but with the right information and resources, ABA providers can ease fears of the billing and claims process.

For more information, you can also check out practice guidelines from the Association of Professional Behavior Analysts (APBA) and autism spectrum-specific guidelines from the Behavior Analyst Certification Board (BACB).

Rethink Behavioral Health provides an intuitive and comprehensive solution to scale your ABA business and ensure client success.

Our one-stop-shop platform offers both Clinical and Practice Management tools along with RBT Training, VB-MAPP licenses, and more than 1500 resources/materials as curriculum pieces.

Schedule a demo today at your convenience!

new york city traffic

ABA & the Mobile Workforce: Managing the Risk of Employee Drivers

This article is based upon a recent webinar presented by Daniel Law, of The Liberty Company Insurance Brokers.

Over the past 14 years, Dan has focused on the design and implementation of insurance and risk management programs for clients globally.

Applied Behavior Analysis (ABA) providers face unique challenges with the clients they serve and the practice they run.

They often relate these issues to operations, clinical data collection and practice management.

However, while ABA providers understand a variety of techniques that affect their clients, sometimes the hurdles that come with managing a business and its employees are difficult to navigate and they need to rely on experts.

One of these challenges is risk management.

Far too often it is only understood as a reactive measure when ABA providers and their employees face issues that affect a business financially or in practice.

However, there are strong benefits to including the right risk management approach in proactive initiatives, like establishing policies for employees who drive.

According to risk expert Daniel Law, of The Liberty Company Insurance Brokers, ABA providers across the country rarely think about the risks associated with employees who drive duringdriving company hours.

Most times, ABA providers have a very young workforce and employees may commute to and from work sites via car or public transportation.

For those who drive and work in a wide variety of environments, there are different levels of exposure.

This can include everything from weather to traffic and by helping clients get from one destination to another.

“The general rule,” says Law, “is if you provide a mileage reimbursement, you have an employee driving on company and your business is at risk if the employee is involved in an accident.”

But every case is unique.

In fact, employees who have a specific location or worksite that they travel to and from consistently may use a car for the commute, which wouldn’t be classified as company time.

To understand the risks, experts like Law say ABA providers should critically analyze guidelines for when an employee is considered to be driving on company time.

When are Employees Driving on Company Time?

  • Driving in between sessions or client homes during work hours
  • Going from a school-based session to a client’s home in the evening

These are just two examples of when an employee may drive on company time and each practice will determine their own policies that correspond with how their business operates.

To implement the risk management approach for employees who drive, each company should first know the fundamentals of the three-step process.

What is the Risk Management Approach?

The risk management approach is a three-step process that centers on identifying, analyzing and responding to risks.

Each environment poses different hazards, so ABA providers must first identify, in their specific operations, where they have risks and analyze how they might impact the business and then formulate a response.

Identifying Areas of Risks

Some risks can be mitigated with appropriate policies, while others cannot.

The risk management approach suggests that those areas of risks that can be avoided should be avoided, like when employees allow clients or children to enter their car.

Exposure in a situation such as this can be tough to manage.

So, if ABA providers don’t know the maintenance of a car or are not providing a company car, Daniel recommends businesses prohibit employees to drive clients in their own vehicles.

Analyzing Risks

Like all other businesses, providers should always analyze risks prior to events.

This is a great way to mitigate risk for a business and establish a precedent that is flexible to implement when employees enter or leave the company.

For example, ABA providers can look at Human Resource policies to determine if they already have a structure in place to require employees to have higher personal auto insurance limits.

If it is a requirement for employees to drive on company time, ABA providers can also require employees to provide regular information on the condition of their vehicles and allow for random or scheduled inspections.

Responding to Risks or Accidents

Some accidents or events are unforeseen and can’t be avoided or overlooked once they occur.

So if an employee drives on company time and is involved in an accident, one of the first things that will be looked at is who is at fault.

The term “at fault” is used to define a point in time when injury or damage occurs to someone or something else, better known as third-party exposure.

It is rarely cut and dry.

A simple allegation of fault can force a business to step in and defend the company, even though the allegations may not have a basis in reality.

The key to handling these situations is staying calm and controlling the situation by formulating an appropriate response at the right time.

Understanding Risk Management

Injury to occupants and employees are often an integral part of the response process.

So understanding the limitations of auto insurance policies and following the rules and procedures associated with the Workers’ Compensation process is essential.

Obtaining a great business auto insurance plan can be a big help.

Each month, Rethink Behavioral Health hosts a webinar with ABA-specific business experts that offer support and guidance for providers.

So be sure to check out the next webinar and arm your practice with the right information to succeed!

Rethink Behavioral Health provides an intuitive and comprehensive solution to scale your ABA business and ensure client success.

Our one-stop-shop platform offers both Clinical and Practice Management tools along with RBT Training, VB-MAPP licenses, and more than 1500 resources/materials as curriculum pieces.

Schedule a demo today at your convenience!

three rows of manilla folders with patient medical records

Translating Medical Necessity Criteria (MNC) for ABA Providers Working with Health Plans

The live webinar for part 3 of our Medical Necessity Criteria Series will take place on Thursday, June 20th, 2019 at 1:00 PM ET.

We will also unveil our brand new, industry-first Medical Necessity Criteria Assessment Tool for ABA Services!

Be one of the first to see it in action by attending the webinar.

Register now!

This piece was based upon a recent webinar presented by Tim Crilly, BCBA.

Tim spent 3 years as Director of Autism Services for a major national health plan and an additional 10 years for a provider group in California.

Conceived over 50 years ago out of the idea that positive gains can be made in an individual’s behavior by applying principles of learning and techniques, the scientific practice of Applied Behavior Analysis (ABA) is a relatively new concept in the healthcare industry.

Although the process has many different elements, health insurance managers and teams often receive only a snapshot of the type of care being offered to individuals in need of treatment.

Health insurance organizations use this snapshot and medical necessity criteria (MNC) to define the benefits they cover for their members.

However, not all snapshots or MNC are created equal.

Medical necessity criteria can vary from organization to organization.

The guidelines help to determine levels and types of care that are considered medically necessary for an individual’s behavioral health.

Many health insurance companies also opt to create their own MNC or LOC guidelines, although there are commonalities.

How Managed Care Teams Use Medical Necessity Criteria

Below are three common phases of interpretation for MNCs:

  • Initialization of care: Set of criteria that determines if care is needed and at what level treatment should be authorized
  • Maintenance of ongoing care: Set of criteria that determines if care should continue at the current level
  • Change or termination of care: Set of criteria that determine if care should change

While the criteria most organizations use was originally meant to simplify the interpretation process, ABA is still widely misunderstood.

The challenge that insurance management teams face when reviewing care is that MNC and LOC guidelines don’t offer interpretations for appropriate levels of care.

Additionally, the lack of consistency in care within the ABA community only makes this challenge greater for insurance management teams, as they review a wide range of care requests that carry different recommended programming levels.

Challenges for Applied Behavior Analysis Providers

ABA providers also face challenges in providing care.

They include:

  • Struggling to align programming approaches and goals with requirements for MNCs
  • Requesting hours for ongoing services that are not in line with MNC/LOC guidelines
  • Pairing reduction behaviors with replacement behaviors
  • Creating caregiver involvement and goals and following through

To help solve the challenges for both insurance management teams and providers, it is important to start with one common element: The MNC.

To get through the metaphorical “front door” or past the initiation of care phase, providers should look at medical necessity criteria for every funding source they have to gain a better understanding of what’s expected at the initial intake phase.

Proceeding with the right level of care in the beginning of the process can also result in a decrease in denials later down the line.

If the original treatment is determined to be an appropriate type of ongoing care for an individual, it should then be clearly justified.

As health care definitions continue to expand, clear and concise justifications for ABA care are more necessary now than ever before.

Insurance care teams often look for the most cost-effective solutions for their business and their members.

Once ABA services become an ongoing offering, health insurance organizations calculate them as new lines of costs that they will attempt to reduce if possible.

How Care Management Teams and Providers Measure Success

To ensure clinically appropriate levels of care, providers must do a better job in gathering information and providing evidence for types and levels of care.

Doing so will help redefine the limitations for care and reduce instances when ongoing care is inappropriately changed or terminated at the expense of those who need it most.

Being smart about goal alignment also makes a difference when insurance management teams review reports.

Providers should ask themselves if they are sending in goals representative of what is outlined in an MNC while considering whether their goals are appropriate for funding through an insurance process.

Any behavior plans should be closely aligned with what is determined in an MNC.

Caregiver programming is perhaps one area with the most inconsistency when it comes to who is being placed in an environment and how much caregiver support is being provided.

This is a big factor for health plans, as an insurance management team evaluates care and wants to see it in programming.

Although goals should align with the MNC as much as possible, providers should also at times focus on additional services that are not outlined in the MNC if doing so will meet the overall needs of their clients.

With the vast majority of providers using digital data systems today, technology should help to make challenges easier to overcome.

Every ABA provider should analyze whether their technology platforms work hand in hand with health plans to ensure they are taking clinically, socially significant and ethical actions in programming and care that align with health plan values.

The technology platforms a provider uses should also offer the right tools and benefits for providers to share with individuals and families as care continues.

Ultimately, the success of health care plans should be measured by titration of care over time; transitions to less intensive care when appropriate; caregiver empowerment and consumer protections for member groups.

However, the measures of provider success are still being defined.

Future Plans

Over the next few years, it will be imperative for providers in the healthcare industry to come together cohesively to avoid regulations imposed by insurance management teams that miss the mark.

Providers should be upfront and coherent in their communication with each other, so everyone can appear on the same page to insurance management teams.

Clinically integrated networks, which can negotiate collectively with health insurance organizations, may be an opportunity for providers work together to protect the quality and consistency of care in the future.

Rethink Behavioral Health provides an intuitive and comprehensive solution to scale your ABA business and ensure client success.

Our one-stop-shop platform offers both Clinical and Practice Management tools along with RBT Training, VB-MAPP licenses, and over 1500 resources/materials as curriculum pieces.

Schedule a demo today at your convenience!