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


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.

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!

This summer, $10 goes a long way at Rethink!Rethink summer deal
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.


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!


Practices for Determining Medical Necessity in Autism/ABA Treatment

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.

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 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, the 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