Missing Piece Blog

Why is eligibility and benefit verification important for ABA therapy?

Inaccurate eligibility information can cost you thousands of dollars in lost revenue.  

Navigating patient benefits is challenging and time-consuming, but it is a crucial step in making sure that providers get paid. Unfortunately, coverage for ABA, speech, and occupational therapy still has limitations and exclusions in many states. Employers who provide self-funded benefits can choose to exclude or limit services, even if the state mandates that autism-related services be covered. For example, ABA therapy insurance coverage may be limited to a maximum of $35,000 in reimbursement per year, but you may receive an authorization that exceeds this cap. It is important to know exactly what and how services are covered to protect the provider and the patient from unexpected denials and bills.  

Eligibility can also change throughout the year in various ways:  

  • Some policies may not follow a calendar year and have a benefit year of July to June for example. It is important to know that the patient’s deductible, out of pocket costs, and the calendar period of the plan.    
  • Maintain open lines of communication with patients about job changes, and how it will affect their insurance coverage. Do they have a grace period? Are they going to utilize COBRA coverage? Will there be new insurance? 
  • Since the application process for Medicaid can be extensive and requires considerable follow up by the patients, providers may have patients who become eligible for Medicaid throughout different times of the year. Be mindful to communicate with the patients about where they are in the process with obtaining any new policies.  

Don’t let patients’ out- of- pocket costs get in the way of providing service, especially since the financial obligations of insurance for ABA therapy can be difficult to understand at times. If a patient does not understand their obligations, they may not be able or prepared to make payments as those becomes due.  ABA therapy in particular can be very costly, and most patients reach their out- of- pocket maximum within weeks or months of starting services, which may amount to $5,000 or more in patient obligations.  Without advance notice, most patients cannot afford or plan for payments of that magnitude. Setting up a payment plan in the initial stages of services helps reduce stress for everyone involved. 

At Missing Piece, we complete a comprehensive ABA insurance eligibility verification process prior to the initiation of services. We also do ongoing verifications.  We clearly explain benefit details to providers so they can offer services within the scope of the benefit limitations.  Reach out to learn more about this and other financial obligations we can help with, such as deductibles, copays, and out- of- pocket maximums. Contact us at 765-628-7400 or weare@yourmissingpiece.com.

Don’t skip this critical step in the revenue cycle!