Why is Eligibility and Benefit Verification Important for ABA Therapy?

Applied behavior analysis (ABA) can significantly improve behavioral issues. Unfortunately, many insurance payers deny their customers the funding necessary to receive this therapy. Payers can justify these denials by citing the complex criteria that determine mental illnesses.

So, payers have constructed a list of requirements clients must meet to receive benefits. Nearly 27% of healthcare claims denials stem from registration and eligibility problems. Prudent ABA practices invest significant resources into verifying patients’ benefits before committing to therapy. 

Here’s why eligibility and benefit verifications are critical for ABA therapy providers. 

Scheduling Mishaps

Failures to account for contractual changes cause many denials across all healthcare specialties. Administrators often assume that because a payer previously covered services, the same applies today. Unfortunately, insurance contracts can change dramatically within a short period. Also, many policies do not match the calendar year. 

Consumers may be unaware of these shifts. This combination of ignorance and failure to review benefits leads to uncovered sessions. Once billers receive a denial for such reasons, the client must pay out of pocket. Avoid this mistake by consistently reviewing relevant contract details when scheduling therapy. 

State Changes

Most states have well-defined standards regarding ASD coverage. These rules primarily affect children, with most offering coverage until 18 or 21 yrs. When moving to a new location/state, ABA providers must carefully review the local coverage guidelines of the payers.  

EHR Integration

Electronic health records (EHRs) store and transmit critical client information. The client’s session/chart is the record’s primary component, but EHRs provide more information than just the chart. They can also provide necessary facts regarding patient eligibility, especially if integrated through EDI. 

Providers who do not use such checks can miss crucial details that expose benefit exceptions. When receiving a new client, always attempt to check their benefits first.

Non-Appealable Claim Denials

Medical coders have the luxury of appealing claim denials and frequently receive reimbursements through appeals. Unfortunately, this fall-back option can make staff complacent when verifying eligibility. Practices must remain mindful that denials almost always negatively impact RCM. Twenty-four percent of potentially avoidable denials are non-recoverable. An additional 60% are only situationally recoverable. Those that are appealable take time away from regular duties. Insurers often place time constraints on appeals, forcing workers to drop other projects. Such delays can completely derail critical billing workflow. 

Mental Health Condition Pre Verification

ABA therapy pre-verification is uniquely demanding. Insurers require detailed documentation demonstrating the diagnosis and the subsequent Plan of Care. If billers fail to have these documents on file, the claim process hits a roadblock. Ensure that a certified BCBA has provided the needed Plan of Care paperwork to receive authorization. 

Plutus Health works to turn the coverage verification your staff secures into revenue. Our expert team synchronizes with providers and insurers to maximize reimbursements. Through this process, we reliably generate higher, faster income for the ABA agency. Build your financial security by contacting a representative today. 

Key Takeaways

1. Failure to account for changes in insurance contracts frequently leads to denials. 

2. Different states mandate varying levels of mental health coverage.  

3. EHRs provide a foundation from which to extract eligibility information. 

5. Insurers mandate that physicians provide documentation certifying a diagnosis followed by a proper Plan of Care.