Total Client Impact: Over $620,000 in Recovered Revenue | Two States, Two Systemic Wins
Key Outcomes: Misrepresentation Corrected in FL | DOI Intervention in IN
Florida: Correcting Misrepresentation and Securing Full-Year Coverage
The Challenge
In 2013, families affiliated with the Florida Institute of Technology (FIT) purchased Golden Rule insurance plans based on broker assurances that ABA therapy for children with autism was covered. When benefit determinations stated excluded coverage, providers and families were blindsided—having already committed to intensive treatment under the assumption of coverage.
The Advocacy
Missing Piece ABA Billing took immediate and aggressive action. We escalated directly to the CEO of Golden Rule, demanding a face-to-face meeting to address the serious implications of the broker’s representations. We argued that Golden Rule’s failure to honor coverage could appear as a misrepresentation of benefits—particularly damaging when involving children with autism and their families.
The Outcome
Golden Rule’s leadership agreed to honor ABA services for the entire benefit year for affected families. As a result, all ABA providers who delivered care were paid in full, and the children received uninterrupted access to essential therapy. At the time, the average reimbursement per child in the ABA program was approximately $120,000 annually.
Indiana: Challenging Third-Party Claim Suppression
The Challenge
In Indiana, Golden Rule began using a third-party administrator (TPA) to process out-of-network ABA claims. This TPA operated independently of Golden Rule’s standard methodology and significantly reduced payment rates—crippling provider reimbursement across the board.
Research into the TPA revealed a pattern of similar complaints regarding underpayment and inconsistent practices. Despite extensive efforts to align Golden Rule and the TPA, no resolution was achieved.
The Advocacy
Because these Golden Rule plans were fully funded, Missing Piece ABA Billing filed a formal complaint with the Department of Insurance (DOI). The DOI launched an investigation and ultimately issued an injunction preventing Golden Rule from continuing to use the TPA for out-of-network ABA claims.
The DOI also facilitated a meeting between Golden Rule, the affected provider, and Missing Piece ABA Billing. Through direct negotiation, an agreement was reached on fair out-of-network reimbursement rates for each ABA code.
The Outcome
After six months of persistent advocacy, this resolution saved the provider approximately $500,000 in lost revenue and established a payment structure that ensured fair compensation going forward.
The Bigger Picture
From executive-level negotiations to state-level regulatory intervention, Missing Piece ABA Billing doesn’t back down when providers—and their patients—are at risk. These dual victories with Golden Rule demonstrate our ability to navigate high-stakes, multi-layered payer issues across states and systems.
Conclusion
At Missing Piece ABA Billing, we don’t just recover payments—we reshape payer behavior, ensure fairness, and protect access to care for vulnerable populations. Our work with Golden Rule in both Florida and Indiana is proof that systemic change is possible with the right partner in your corner.