Missing Piece Blog

Why is eligibility and benefit verification important for ABA therapy?

Did you know that 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 ensuring providers get paid. Unfortunately, coverage for ABA, speech and occupational therapy still has limitations and exclusions in many states. Knowing whether ABA therapy is covered by insurance will save many unfortunate billing issues down the line. 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, insurance that covers ABA therapy may be limited to a maximum of $35,000 in reimbursement per year, but you may receive 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.  

The eligibility factors to look out for

Eligibility can also change throughout the year in various ways. Let’s take a look at some of the changes to be wary of.  

  • Some policies may not follow a calendar year and have a benefit year of July to June, for example. It is important to know 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 they 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 at different times of the year. Be mindful to communicate with the patients about where they are in the process of obtaining any new policies.  
  • State changes can primarily affect children and their ABA therapy insurance coverage. Patients should know that moving to a new state will require ABA providers to review the local coverage and eligibility.

Stay informed and provide information for patients

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 become 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 in-patient obligations. Most patients cannot afford or plan for payments of that magnitude without advance notice. Setting up a payment plan in the initial stages of services helps reduce stress for everyone involved. 

Get the best ABA billing service at Missing Piece

At Missing Piece, we complete a comprehensive ABA insurance coverage eligibility verification process before the initiation of services. Our ABA insurance billing service also includes ongoing verifications. We clearly explain benefit details to providers so they can offer services within the scope of the benefit limitations. Contact us to learn more about this and other financial obligations we can help with, such as deductibles, copays, and out-of-pocket maximums. Don’t skip this critical step in the revenue cycle!