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.

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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, a 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.

In order to help with both of these common issues, Emily offers a number of 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 in 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 significant need or effects that occurred in cases when an issue was left untreated or undertreated.

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 of course 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!

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 on a global basis.

Applied Behavior Analysis (ABA) providers face very unique challenges with the clients they serve and the practice they run. These issues are often related to operations, clinical data collection and practice management. However, while ABA providers understand a variety of techniques that effect 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. In many cases, ABA providers have a very young workforce and employees may commute to and from work sites via a 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 work site that they travel to and from on a consistent basis may use a car for the commute, which wouldn’t be classified as company time.

In order 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 be driving on company time and each practice will determine their own policies that correspond with how their business operates. In order 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 business, 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 does drive 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 generally 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 simply 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. 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!