Despite recent developments in the healthcare industry that now ensure that ABA therapy is covered by medical insurance, it can still be challenging for ABA practitioners to claim for their services. It’s crucial to bill the correct ABA codes based on the delivered service and use the correct modifiers to ensure a one-to-one match with all the claim details. .
Our guide unpacks the ABA insurance claim cycle and explores everything you need to know about the process so that you can improve your claims process.
Understanding ABA insurance claims: what is a claim cycle?
A claim is the request that an individual or healthcare provider makes to a medical insurance company to provide payment for specific services. A claim cycle in medical billing is simply all the steps involved with processing a claim once it has been made.
The claim life cycle consists of several steps:
1. Verify patient eligibility
Before you submit a claim to a patient’s medical insurance company, you must verify that they have the necessary coverage.
While this can be done after treatment has begun, some Medicaids require benefits to be checked prior to treatment, so it’s recommended that this step be done before any services are rendered. This will help avoid any surprises around payment of treatment should the insurance company not offer coverage (or not offer as much coverage as the patient expects).
2. Capture the necessary information for the claim
Firstly, it’s important to note that there needs to be a discussion about submitting clinicals for pre-authorization before discussing the claim. Once you have verified a patient’s eligibility, you’ll need to complete a claim for any services rendered. A claim form (whether paper or electronic) will outline all the information you require, including a patient’s personal details, policy number, and the correct CPT codes for the services you have provided.
3. Submit claim to insurance
Once you have captured the necessary information in your claim forms, you’ll need to submit the claim. Claims can be submitted via mail or electronically via a payor provider portal (we cover these methods in more detail below).
4. Insurance claim review (or claim adjudication) occurs
After a claim has been received at the clearinghouse who will review it to ensure it is correct, it will be sent to the payer. The payer is any organization that pays for the services provided by a healthcare provider, and can include insurance companies, government programs, and employers. If the claim is found to be acceptable, it will be sent for processing. However, a claim can be rejected by the clearinghouse or payer prior to processing. Rejection usually occurs because the claim has incomplete, outdated, or otherwise incorrect information.
5. Settlement or denial is confirmed
Once a claim has been processed, the ABA provider will receive an update from the payer on whether their claim has been settled or if it has been denied.
If the claim is settled, the provider will receive payment from the insurance company and an explanation of benefits (EOB). An EOB is a document that will unpack what the insurer has covered from the claim, as well as any outstanding amounts that the patient will be required to cover. If the claim has been denied, you’ll need to appeal the denial and send a corrected claim, or have the claim reviewed.
6. Payment of remaining balance
If a claim is processed out-of-network, the patient is responsible for the assigned patient responsibility and the remaining balance (also known as a balance bill). However, if a claim is processed in-network, the patient is only responsible for the assigned patient responsibility.
How to submit an ABA therapy claim
As we previously touched on in the section explaining the claim cycle, there are two ways to submit an ABA therapy claim:
1. Mail
Some medical insurance companies may not have an online portal for claims or may not be affiliated with a clearinghouse. In this case, you’ll be required to submit a claim using the corresponding forms and all the necessary additional documentation to the insurance provider. This claim will need to be submitted through certified mail so that it has a tracking number.
2. Electronically
You can also submit claims electronically through an insurer’s online portal. You may be required to fill in the relevant paper forms by hand and then scan and upload them to the online portal, or you may be able to fill in the forms digitally and then submit them directly to the portal. In both cases, you’ll need to scan and upload the additional supporting documents.
Other organizations that can assist with submitting ABA claims
While it’s entirely possible to handle ABA billing in-house, you can also seek the services of a clearinghouse or third-party ABA therapy billing provider to assist you with the process.
Clearinghouse
A clearinghouse is an organization that helps facilitate payments to healthcare providers by reviewing claims before they are submitted electronically to a medical insurance company. This process is known as claim scrubbing and involves checking the claim for mistakes and ensuring that the payer will process the claim.
Once the claim has been scrubbed, the clearinghouse will securely submit the claim to the relevant payer electronically.
It’s important to note that using a clearinghouse doesn’t mean that your claims will never be rejected. Rather, a clearinghouse will improve your revenue cycle by lowering the chance that your claim will be rejected.
Ultimately, a clearinghouse’s job is to ensure a claim is as correct as possible so that reimbursement is quicker.
Third-party ABA therapy billing provider
Another organization that can make your ABA therapy billing even easier is a dedicated third-party ABA therapy billing service. Instead of merely scrubbing a claim, this provider will handle virtually the entire claims process on your behalf, including verifying eligibility, managing the claim, and patient billing.
By partnering with a dedicated ABA billing service provider, you’ll ensure that your billing is handled by a team of experts with an in-depth understanding of your particular healthcare field. This will result in even faster processing and reimbursement of claims as there will be less chance of a rejected claim since the third-party provider has handled the billing process.
Let Missing Piece handle your ABA insurance claims for you
If you find yourself struggling with ABA billing guidelines or ABA billing software, or simply think that your time could be put to better use in your practice, be sure to reach out to Missing Piece.
Missing Piece has been providing ABA providers with ABA billing services for more than 10 years. Our company’s turn-key billing solutions provide you with access to payer and billing expertise that ensures efficient reimbursement, and also frees up your time to deliver even better care for your patients. Our solution is also scalable and can adjust to the needs of your practice as it grows. This avoids any stress or difficulties associated with switching providers in the future as your billing needs change.
Contact us to learn how Missing Piece can simplify ABA therapy billing for you and your practice.