Streamlining Utilization Review for Applied Behavior Analysis

By: Dana D’Ambrosio, BCBA, LBA

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Applied Behavior Analysis as a covered benefit is a relatively new venture for Behavior Analysts. With 50% of currently practicing BCBA’s having been certified in the last 5 years and insurance submission processes not included as part of their graduate curriculum, the variability in quality, style and data in treatment plans submitted for authorization leads to an arduous review process for health plans.

Combining the large discrepancies between provider treatment plans, the array of severity of symptoms and treatment methods, unclear documentation, and specific health plan requirements with complex medical necessity criteria, utilization managers are being set up with a subjective, inconsistent decision-making process.

Objectivity: How It’s Skewed

Managed Care Organizations and Health Plans have different staffing options in terms of who review ABA treatment plans for authorization of services for members with Autism. The gamut runs from nurses to social workers to BCBAs and yet, regardless of credentials, there is always a significant level of subjectivity across reviewers.

The problem lies in the experiences and perspectives of the reviewer, even when comparing treatment plans to the most stringent of medical necessity criteria.

As reviewers individually analyze each member and their treatment plan, while considering the extensive list of other factors: length in treatment, historical progress/regression, symptoms and severity, co-morbid diagnoses, barriers to treatment etc., they need to ensure high quality of care is being provided, and the benefit is being used appropriately. This process ultimately leads to great disparities in inter-rater reliability between reviewers.

Standardizing the Review Process

To increase objectivity and accuracy of decision making and reduce opportunities for outcomes that lead to avoidable harm or wasteful allocation of resources (BACB Guideline 3.01), it is imperative that health plans initiate a standardized review process for autism care management.

By consistently applying ABA benefits and quantifying response rates to treatment, payors ensure high quality of care is provided for services that are, in fact, medically necessary. With a decision-making algorithm, for instance, reviewers can dissect treatment plans, regardless of length/style, into a uniform layout of the most relevant information, while analyzing and monitoring members and their progress on an individual basis.

The key component of such a model is to guarantee each plan is still reviewed on its own, as each case has its own nuances which need to be accounted for, yet the structured elements which guide the decision are reviewed in a regulated way.

By having a standardized tool that ensures submission of a complete medical record, the information expected for treatment plan submission is clearly defined for providers (BCBAs) and the reviewer can then use this as a guide for pinpointing conversation topics, ultimately reducing the communication barrier between the health plan and provider. This shortens the review process and decreases latency to care.

Rethink Care Management’s Solution to Optimize Medical Necessity Review

Rethink’s Medical Necessity Assessment (MNA) is a patent pending clinical decision-making model to determine the medical necessity for ABA services which recommends an evidence-based treatment approach, including appropriate dosage of ABA therapy. Utilization reviewers systematically review providers’ treatment plans and use the tool’s recommendations to guide a personalized care decision.

For more information about the MNA tool, click here.

How Rethink Care Management Partners With Payors

Rethink Care Management is part of Rethink First, a global health technology company providing cloud-based treatment tools, training, and clinical support for individuals with developmental disabilities and their caregivers.

The need on the payor side for validating that medical necessity criteria are being met when treatment plans are being submitted by providers is complex. As such, Rethink has expanded its platform to develop tools for care managers, which includes the above-mentioned Medical Necessity Assessment, among other supports for Care Management and Member Engagement.

To learn more about the solutions, contact us.

About the Author

Dana DAmbrosio Headshot

Dana D’Ambrosio, BCBA, LBA

Health Plans Solution Manager

Dana is a Board Certified and NY state Licensed Behavior Analyst who has been in the field since 2011. After providing treatment and supervision in clinic, school, and community settings, she transitioned to the realm of Managed Behavioral Health. She has experience in both utilization and care management for ABA benefits and has taken on the role of Health Plan Solutions Manager at Rethink where she focuses on furthering the reach of the Medical Necessity Assessment and other solutions with health plan partners.

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