Managing ABA authorizations tends to be one of the more common pain points with ABA billing. Despite the hurdles that come with this process, authorization management is necessary to service your patients most effectively and to increase financial efficiency within your organization. Two areas to watch out for when it comes to authorization issues are over-utilization and under-utilization.
Over-utilization can result in services being provided that cannot be collected. On the other side of the coin, under-utilization of authorization can result in patients not receiving the full medically necessary services they are approved for. To a further extent, continuous under-utilization holds the potential for reductions in future authorizations.
To help reduce and even eliminate authorization issues such as these, there are three focuses we encourage you to keep at the forefront of your thought process: consistent monitoring, clear communication, and schedule accessibility.
Let’s take a closer look at these functions.
Monitoring
The most important key to successful ABA benefits and authorization management rests in consistently monitoring your active authorizations. Weekly status check-ins are imperative to maintain a current understanding of authorization usage. We would encourage you to designate a single team member to be responsible for monitoring authorizations, maintaining awareness of usage, and reviewing the start and end dates. If your organization works with a revenue cycle management partner or ABA billing company or has specialized management software, this may be a service that you can take advantage of. Maximizing begins with monitoring and ensuring that you know the ins and outs of insurance for ABA therapy.
Communication
In the same way that the act of monitoring can lead to successful authorization management, communication is an essential factor. Frequent communication should occur between all parties involved to ensure that neither over-utilization nor under-utilization pitfalls come into play. Including therapists, BCBA(s), administrators, caregivers, family members, and internal teams to be part of the bigger conversation is the best way to ensure everyone is on the same page.
If a family is having trouble maintaining a consistent schedule, this could prevent the patient from receiving the full services for which they are approved. Clear communication with the family will help address attendance issues and improve their understanding of why they should use authorized services, and highlight the importance of insurance reimbursement rates for ABA therapy.
Scheduling
A final key to prioritize when managing authorizations – and one that goes hand in hand with good communication – is scheduling. If possible, give your scheduling department access to authorization usage information so that adjustments can be made in accordance with timeframes and usage. Open lines of communication between the billing team and scheduling department will help ensure that scheduling complies with ABA billing rules, requirements, and other authorization usage factors.
Despite more common difficulties that come with the authorization process, prioritizing these three focuses can help reduce pain points and lost revenue from developing into larger issues. Consistently monitor. Clearly communicate. And stick to your schedule.
The Benefits of Receiving Prior Authorizations From Insurance Companies
Insurance authorizations are a key part of providing services, but they can be confusing and difficult to manage in some practices. Prior authorization is a process required by many health insurance companies. Without it, the patient’s procedure, medication, or service may go unpaid. In most situations involving ABA authorizations, it is critical to have a behavioral health plan that clearly demonstrates the need for these services as medically necessary for the patient. There are various steps to this process.
- Verify benefits: The first step is to verify the provider is within the network (or considered out of network with benefits) with the insurance carrier. Providers must gather proof of insurance that covers ABA therapy from the patient to start the authorization process. This process must happen before the patient receives any type of treatment or care.
- Assessment authorization: The next step in the process involves obtaining assessment authorization through a “treatment request form.” This form lists all background information about the child and the service provider. It may also include credentials and the necessary service codes for the type of therapy being provided. The correct billing codes reflect the ABA therapy, including the hours necessary to complete the assessment.
- Assessment: The next part of the process is approval for the assessment. This is not a full approval to provide care, but just to provide an assessment based on the approved number of hours by the insurance provider. This step lets the provider begin working with the patient for a formal evaluation.
- Treatment plan creation: After the assessment, the provider develops a treatment plan for the patient. This is an elaborate document that outlines the services to be provided, along with goals for the future. The provider can meet with the parents and the patient at this time to go over the treatment plan. That is an important step because it enables good communication on the expectations of care. If everyone agrees to the plan, it is signed by all, and the next step in authorization can occur.
- Ongoing authorization: The process of obtaining authorization for ongoing care is much the same as the previous step to receive approval for the assessment. This step involves getting approval to provide care for a set number of hours over a six-month period. This may take a bit more time than other authorizations for insurance for ABA therapy due to the need to determine if the care is medically necessary. In some situations, the insurance provider may require a peer review or live review. A case manager may want to review the treatment plan to ensure it is the best choice.
- Treatment starts: Once authorization occurs, treatment can begin on an ongoing basis. It is possible that authorization to continue care will be necessary over time. Usually, after six months of care, the authorization process must begin once more.
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