Prior to 2019, ABA therapy providers encountered significant obstacles in billing as they were forced to make use of generic billing codes to process ABA claims. This stipulation caused a number of issues for ABA practitioners and others involved in ABA claims processing. Although 2019 saw the introduction of specialized CPT I and CPT III codes for ABA billing, challenges in this area persist.
We explore the complexities surrounding ABA billing and offer strategies to mitigate some of these challenges.
What are CPT codes?
Before we discuss the issues surrounding ABA billing, it’s crucial to understand Current Procedural Terminology codes, known as CPT codes in medical billing. 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 are temporary codes for any new procedures, services, and technologies that CPT I codes may not cover
What’s important to note is that CPT codes are not the only challenges faced in ABA billing.
Why is ABA billing so complicated?
Numerous factors contribute to the difficulties encountered in ABA billing. Below are some of the most common causes.
Issues with CPT codes
As previously mentioned, CPT codes frequently serve as a primary source of billing and claim issues with ABA health insurance providers. Challenges associated with CPT billing codes can include frequent changes in codes, the misuse of codes for specific services, omissions in code entry, and various other code-related complications.
Incorrect patient details
Even the smallest discrepancy in patient data, regardless of its apparent triviality, can lead to complications in submitting ABA claims. 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.
No physician referral
Additional issues may arise if you fail to get a referral from a physician for ABA treatment. Most payers require the Diagnosis Reports showing the DSM-5 criteria have 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 ABA billing claim submission can be challenging is due to the implementation of systems designed to flag potentially fraudulent claims. These systems are usually automated and will 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.
Illegible writing
It may be jokingly said that doctors and many other healthcare professionals have sloppy writing, but if a claim is made in handwriting (as opposed to a typed text) and is too hard to read, an insurer could reject the claim.
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 service in the past, it’s crucial 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 claim submission issues.
Check your patient’s insurance information and confirm your services 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 all the information the health insurance provider requires is correctly entered before you finalize your claim submission, as it can be much harder to correct 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, it’s imperative to ensure that it’s being submitted using the correct channel, be it 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 Missing Piece
The easiest way to avoid claim submission issues is by outsourcing ABA billing services and partnering with 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.