Applied Behavior Analysis (ABA) therapy is a crucial intervention for autistic children or those with similar developmental disorders. However, understanding the nuances of medical billing can be complicated for both providers and clients.
Insurance is always a tricky industry to understand in-depth and is also one of the most common confusion areas in ABA medical billing. Clients must understand out-of-network insurance benefits compared to in-network benefits, how this could impact their payments, and more. Those rendering ABA therapy services need to have a thorough understanding of out-of-network benefits to help their clients and streamline their payment processes.
Let’s explore the topic a bit more to gain a better understanding and insight into how it could impact your patients and their families.
What is an out-of-network provider?
Before exploring the complexities of ABA medical billing with regard to in-network and out-of-network providers and benefits, it’s important to understand the foundational terms and what their distinctions are in the insurance industry.
- Out-of-network provider: If you want to define an out-of-network provider, it would be an ABA therapy company that doesn’t have a contractual agreement with any specific insurer. They charge what they believe their services are worth.
- In-network provider: An in-network provider is a company that has a contractual agreement with an insurance provider. The agreement covers the services provided and the rates at which they will be reimbursed for their services.
How do out-of-network benefits work?
As mentioned, an out-of-network provider isn’t contractually obligated to any one insurance provider. However, that doesn’t mean that clients and practices cannot claim some of their bills back from their insurance provider.
Many insurance companies have out-of-network benefits that cover treatment at an ABA therapist. Here’s how these benefits work.
Reimbursement rates
Keeping track of reimbursement rates is an integral part of ABA therapy documentation best practices. Whether a provider is in-network or out-of-network has a big influence on the reimbursement rate for services rendered.
As mentioned, in-network providers have a pre-negotiated rate for their services. This rate is normally lower than that of an out-of-network provider, with the compromise that they are likely to have more clients due to referrals from the insurance company.
An out-of-network provider charges what they think their services are worth. They either get paid upfront by the client, who claims from insurance, or they will claim from the insurance directly. Most insurance providers will not cover 100% of out-of-network rates, which could mean that the ABA provider gets 70% of the final amount, for example, and the client must pay the shortfall.
Financial responsibility
The client is responsible for paying whatever the insurance company does not cover. The client’s out-of-pocket costs are lower when using an in-network provider, and they will most likely only have a small co-pay or deductible amount. They must cover their outstanding bills directly with the medical company.
Paperwork and administration
Behind every insurance claim is a trail of paperwork and administrative overheads. The admin side of ABA therapy claims can be complex and will vary from practice to practice. An in-network provider will have set administrative processes in place that make claim submissions and approvals much more straightforward.
An out-of-network provider will face more hurdles, and there is a high number of out-of-network provider appeals due to the heavy lifting when it comes to paperwork. In some cases, the client will have to submit their claims to the insurance company directly, which means they have to get all the paperwork together from their provider. This increases the chance of human error, denials, and claims rejections, such as those that stem from entering the wrong ABA billing codes and more.
Availability
Waiting times and availability can greatly impact the therapist clients choose. In-network providers tend to have a higher volume of clients, which could make booking a session quite challenging.
Out-of-network providers charge more and can afford to have fewer clients, which results in increased availability. Clients are likely to get appointments much quicker and also have the opportunity of a more flexible schedule than might be offered at an in-network provider.
Flexibility in operational obligations
In-network providers have strict contractual obligations with insurance companies that dictate terms of service provision, rates, reimbursement, and more. These terms are integral to maintain and meet as they ensure the providers remain within the in-network provider status.
Out-of-network providers have no such contractual obligations and, therefore, have more autonomy in their operations. This means that they can offer a range of services and adapt them according to individual needs. However, there is no guarantee that insurance will cover all services provided, and the company needs to negotiate rates on a case-by-case basis.
Does Medicaid cover out-of-network providers?
So, how to know if you have out-of-network benefits? This will vary hugely depending on the type of insurance provider. Medicaid is a government-run healthcare program, and it does cover some out-of-network services. However, if you or your client are unsure whether your services can be claimed, it’s best to contact the insurance company for clarity and authorization before providing treatment. Managing your ABA authorizations is essential in your revenue cycle.
Missing Piece provides the best ABA billing services
Despite the complex nature of in-network and out-of-network benefits and billing, a strategic focus on this area can streamline your billing process and cash flow. Missing Piece is an expert in ABA therapy billing services and provides crucial assistance for practices that want to maintain operational efficiency and financial help.
Contact us today for comprehensive billing solutions that will allow you to spend more time with your clients and less time managing your billing.