Before 2019, ABA therapy providers faced numerous challenges with billing as they were forced to use generic billing codes to process ABA claims. As a result, ABA practitioners and anyone else involved in ABA claims processing faced numerous problems. Despite the introduction in 2019 of ABA billing specific CPT I and CPT III codes, ABA claims still present many challenges.
We look at why ABA billing can be so problematic and share some advice on how to avoid some of these difficulties.
What are CPT codes?
Before we get into the issues around ABA billing, it’s crucial to understand Current Procedural Terminology codes, commonly known as CPT codes, since they often contribute to ABA billing issues. These codes are the standardized method for billing health insurance providers and fall into three categories: CPT I, CPT II, and CPT III billing codes. CPT I codes are for specific procedures and services and are numbered from 00100 to 99499. CPT II codes are supplemental tracking codes that can be used for performance measurement. CPT III codes, on the other hand, are temporary codes for any new procedures, services and technologies that CPT I codes may not cover.
Now that we understand more about these codes, it’s important to note that they’re not the only reason why ABA billing can be difficult.
Why is ABA billing so complicated?
There are many reasons why ABA billing can go wrong. Here are some of the most common causes of problems.
Issues with CPT codes
As we’ve already mentioned, CPT codes are often one of the most common causes of issues with billing and claiming from an ABA health insurance provider. The problems with CPT codes can vary from changes in codes (a common occurrence), to using the wrong code for a service, to forgetting to add a code and other code-related difficulties.
Incorrect patient details
Any kind of error in a patient’s information, no matter how small or seemingly insignificant, will cause problems with ABA claim submissions. For a claim to be processed properly, it must contain the exact information required, whether that’s a patient’s name, date of birth, sex, policy number or any other personal details.
Not getting a referral from a physician
Additional issues may arise if you fail to get a referral from a physician for ABA treatment. Most payors require the Diagnosis Reports showing the DMS-5 criteria has been met to authorize ABA therapy.
Failing to meet submission deadlines
Once a service has been provided, there’s a window of time in which billing must occur. If you miss this window, a health insurance provider may reject your claim. This billing window differs from one insurance company to the next and is referred to as a timely filing limit.
Accidentally submitting multiple claims
Whether it’s due to a human or technical error, it’s possible for a claim to be submitted more than once accidentally. In these situations, both claims may be canceled, and you’ll be required to submit a new claim from scratch.
Fraudulent claim prevention
Another reason why ABA billing claim submission can be difficult is that systems exist to flag potentially fraudulent claims. These systems are usually automated and are designed to notify the health insurance provider of any upcoding (a claim for a high-cost service that was not provided), undercoding (a claim for a lower-cost service that was not provided), unbundling of services (some services are usually bundled together at a lower cost), or other suspicious looking claims.
It may be somewhat of a joke that doctors and many other healthcare professionals have sloppy writing, but if a claim is made in handwriting (as opposed to a typed text), an insurer may reject the claim if it’s too hard to read the submission.
Not verifying a patient’s coverage or authorization with their insurer
Because a patient’s ABA insurance coverage may vary depending on the health insurance provider, it’s important to verify that their health insurance covers a particular service before that service is provided. This can help avoid situations in which the health insurance provider does not cover a particular service and the payment reverts to the patient, who may or may not have the funds to pay.
The ABA services covered by a particular health insurance company may also change, so even if they’ve covered a particular ABA service in the past, it’s essential to ensure that you’re up to date with their current coverage to avoid additional billing issues.
You may also be required to get authorization from an insurer before providing a service for a payment to be processed.
How to avoid ABA claim submission issues
As complicated as ABA billing and claims submission can be, there are steps you can take to avoid any ABA claim submission issues. Here’s how to bill insurance for ABA therapy while minimizing any claim submission issues:
Check your patient’s insurance information and confirm that the services you are providing are covered
Before you provide ABA therapy services to a patient, ensure that you have the correct insurance information for the patient and that their insurance covers them. This will allow you to address any issues beforehand, such as an incorrectly supplied policy number, lack of coverage for a particular service, or exhausted health insurance funds.
Ensure all information is captured and submitted correctly
One of the simplest steps to avoid potential denials is to ensure that you correctly capture and submit all information, such as a patient’s name, date of birth, and age, when making a claim. Make sure you verify that all the information the health insurance provider requires is correctly entered before you finalize your claim submission, as it can be much harder to fix once the submission has been made.
Don’t miss submission deadlines
As previously mentioned, deadlines for claims submissions will differ depending on the health insurance provider. As a general rule of thumb, be sure to send your claims as soon as possible or reach out to confirm what an insurance company’s submission deadlines are to avoid missing your window to file the claim.
Make a submission using the correct channels
Regardless of whether you’re submitting a claim digitally or on paper, you must make sure that it’s being submitted using the correct channel, regardless of whether that’s a postal address, email address, electronic payer ID, or any other claim submission method.
Make sure you’re using the latest codes and processes
As mentioned, ABA codes and processes can and do change, so make sure you (or your billing staff) are using the latest codes and processes to avoid any unexpected denials.
When in doubt, ask for help
If you’re unsure whether a submission is correct, contact the insurance company to confirm that everything is in order. This may help you fix any potential issues before the insurer denies your claim and requires that you redo the entire submission.
Simplify your ABA billing and claims submissions with Your Missing Piece
The easiest way to avoid any claim submission issues is by outsourcing and partnering with Your Missing Piece. We offer ABA therapy billing and consultation services to ABA practices across the United States. We can take over the burden of complicated ABA billing so that you can focus on providing your patients with the attention and care they need while dedicating more time to other day-to-day tasks in your ABA therapy practice.
Contact us to find out more about our services and how we can assist you.