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by Plutus Health

December 28, 2019

Importance of Prior Authorization In Billing For ABA Providers

by Plutus Health
Plutus Health Inc

Getting Health Insurance Coverage for Autism Treatment has become more widespread over the last decade, which largely covers essential treatments like Applied Behavior Analysis (ABA). With a Prior Authorization in place, ABA providers can have the approval or “authorization”by insurance providers, “prior” to prescribing the therapy services to a client.This “pre-certification” system is very important for the healthcare provider to ensure uninterrupted treatment and consistent Revenue Cycle Management (RCM).

What Is Prior Authorization and How Does It Work for ABA Providers?

Prior Authorization or Pre-Authorization is an essential step in the process of getting health insurance to cover certain services. Medical Insurance Companies or Payers refer to a document or PA form, that healthcare providers need to fill up, specifying the services needed by a client such as ABA Therapy, or other procedures that are necessary for the treatment. The insurance company will then review the document and decide the approval of the authorization.

It is the responsibility of the client or their family to inform the healthcare provider that they have health insurance and about the requirement of prior authorization for medical billing. Whereas, obtaining the PA is the Healthcare Provider’s responsibility, as they would then need to contact the insurance company to apply for authorization. Usually, if a health care provider is unable or fails to send the application for PA then in the most legitimate practices, it indicates that the healthcare provider should absorb the treatment costs instead of passing it on to the client to pay for them.

Therefore, getting a PA on time is crucial for Medical Billing to avoid unwanted complications and/or losses for both clients (and their parents/guardians) and healthcare providers.

 

To obtain a PA for ABA Therapy, healthcare providers and family of the client need to collaborate and conduct the following steps:

 
     ●      Provide Basic Intake Information to the Insurance company to start the process. The information includes a child’s demographic information, medical history, family history, etc. according to the requirements set out by the Payer.

     ●      Provide Initial Treatment Plan requesting Authorization for treatment. Most insurance companies allow ABA therapists a few hours of initial sitting with the client to create a basic framework of the treatment plan.

    ●      Keep Track of The Authorization Expiry, in case you are applying for renewal of authorization, have ample time in hand before you can be sure that you will get the PA approval. Consider having at least two weeks beforehand while you submit your next authorization for 6-months.

How Insurance Policies Cover ABA Therapy

On a general scale,Commercial Insurance Policies only apply when a diagnosis report confirms Autism Spectrum Disorder in a child. Even though there are children who undergo ABA Therapy for behavioral abnormalities other than Autism, health care insurances usually do not cover for such treatment.

Prior Authorization - An Essential Part in Revenue Cycle

While ABA facilities,be it hospital departments, or ABA Clinics, are into the continual process of improving lives, the process of how a client pays for the healthcare services does change from time to time. Therefore, it is also essential for the ABA Provider establishments to have a sustainable financial process and significant policies to organize the different functionalities like insurance claims,administering client data and the whole process of revenue generation. Revenue Cycle Management (RCM) is the dynamic process of organizing the billing cycle in a holistic manner for the above.  

Therefore, when a client asks for their therapy to be paid through insurance coverage, it is essential that the process is handled on priority by the ABA Provider. While this optimizes a client’s access to quality healthcare at the convenient time, this also signifies that the ABA Providers are able to reach out to more kids.

The most essential role of a Prior Authorization is to have the confirmation that the specified therapy will be funded by the Payer, and this reduces the chances of interruptions in treatment due to monetary issues.

 
Benefits of Having A Prior Authorization for ABA Therapy Are :


     ●      Client’s parents and ABA Providers can both be sure about the financial obligations and the costs covered by the Insurance Company

     ●      Reduced chances of Denials

     ●      More focused and uninterrupted treatment for clients

     ●      Reduced chances of write-offs

     ●      Consistent RCM

 
Moreover, in case an authorization is  not approved or “denied” due to unsanctioned treatment procedures or incomplete/inaccurate information in the medical document, then both the healthcare provider as well as the client’s family  has prior knowledge that they need to bear the expenses that they may not be prepared to pay for. Therefore, having a Prior Authorization is highly important for Medical Billing for both healthcare providers and clients.



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