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 more than 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 greatly 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 for.
- Maintenance of ongoing care: Set of criteria that determines if care should continue at current level.
- Change or termination of care: Set of criteria that determines 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 instep 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. In order 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 Team 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 that are 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 of the areas 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 platform 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. Over the next few years, it will be imperative for providers in the healthcare industry to come together in a cohesive manner 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.
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