2024 ABA Billing Guide: Challenges, Solutions, and Best Practices
Mastering ABA billing means staying current with changing guidelines. This comprehensive article provides the latest ABA billing updates. Learn from billing experts about common challenges, solutions, and best practices for every stage of ABA billing.
Inside this article:
How to Bill Insurance for ABA Therapy
Billing insurance for ABA therapy involves several steps before and after providing the service. Key steps include confirming eligibility and prior-authorization and then using the right codes and modifiers on the claim. It’s important to keep track of the different payer and state requirements.
"ABA therapy is a relatively new field that presents unique challenges when it comes to billing,” says Dawn Price, Director of revenue cycle management at Little Spurs Autism Centers and Little Spurs Pediatric Urgent Care. With 20 years of experience in RCM and clinic operations, Price is adept at negotiating competitive rates with payers, credentialing, implementing systems and process improvements, maximizing reimbursements, and managing diverse teams.
Price says the ABA billing process reflects ABA therapy’s unique nature and the clients' particular needs.
“In ABA, clients usually need prolonged, consistent care, an uncommon situation in most medical fields,” Price says. “Also, whereas some kiddos may only need a few hours of therapy a week, others need therapy full-time. As a result, insurance payers usually approach ABA on a case-by-case basis and almost always require pre-authorization before covering any treatment.”
Rajgopal HK, Associate Director at Plutus Health Inc., says that ABA billing is complex because there are no uniform guidelines or rules. He says the lack of standardization may relate to the fact that Medicare is primarily for people over 65 and doesn’t cover ABA therapy.
"Medicare is often one of the first payers to offer new therapies like ABA," Rajgopal says. "In many cases, private payers look to Medicare to set guidelines. However, because ABA therapy primarily serves children rather than older individuals, Medicare never established this standard. Consequently, many private payers made their own guidelines, creating multiple-payer requirements rather than a unified system. This diversity in payer and state guidelines can be very challenging to manage."
Price provides this broad overview of how the ABA billing claims process works:
“A parent will call us and ask us to evaluate their child for ABA therapy,” she says. “After we gather their basic information, the front-end staff will schedule an appointment at least a few days out so we have a few days to confirm their eligibility or give them other options to pay for care.”
Price says the parent's only task should be calling to make the appointment.
“The clinic should do the heavy lifting of figuring out whether and how the parents’ insurance covers ABA therapy,” she says. “The front office will contact the parent’s insurance company to see if ABA therapy is a benefit and determine whether we need to make a pre-authorization request. Then, we’ll call the parents back and let them know what we found out from their insurance company, give them a quote of benefits, and start working on what a reasonable treatment plan is for them.”
After the appointment, the provider will submit a claim based on the parents' specific payer requirements.
“Every insurance company has their own ABA billing guidelines that we have to follow regarding CPT codes, modifiers, and how they categorize RBTs and BCBAs,” Price says. “There are also specifics regarding prior-authorization, the number of session hours we can bill, and more. It’s a very complex and unique process that requires an expert ABA billing team dedicated to the task.”
Key Takeaways:
- Insurance payers do not follow a uniform ABA billing process, so pre-authorization is key.
- Tracking and managing authorized therapy hours for each client can present challenges.
- ABA CPT codes are generally straightforward, but selecting the correct modifier can be challenging because it changes based on the state, payer, and provider credentials.
- Practice management software automates tasks such as verifying authorization hours, assigning CPT codes, and flagging problematic claims.
- Experts recommend integrating ABA billing into a comprehensive revenue cycle management process and outsourcing RCM to an experienced ABA billing and collections team.
Steps in the ABA Billing Cycle
The ABA billing cycle begins before the service. The front-end staff checks client eligibility, provider credential requirements of the payer, and pre-authorization. During the service, providers carefully document the session. Then, the billing team sends claims according to each payer's requirements and follows up on any denials.
Here's a summary of the steps in the ABA billing cycle:
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Eligibility & Benefits Verification and Prior-Authorization
The ABA billing process starts as soon as a parent makes an appointment."The billing cycle begins when a child's family requests service from a clinic," Rajgopal says. "Before the appointment, the front-end staff checks whether the kid's parents' insurance covers an initial assessment. Then, they contact the family to tell them what they learned."
Rajgopal notes that the initial evaluation will help determine how many hours of therapy the child may need. "After the first few sessions, the BCBA will determine the appropriate continuation of treatment, like the frequency and duration of ABA therapy."
After the assessment, the provider will submit documentation outlining the treatment plan to the insurance company. The plan will include the therapy goals and the expected duration and frequency of ABA sessions. Then, it's up to the payer to either accept or reject that authorization for the recommended ABA treatment.
If the insurance company authorizes the service, it's for specific "units of service," where one unit is usually 15 minutes of therapy. The authorization usually lasts for six months. If the provider wants to continue the therapy after six months, they'll have to submit more documentation to renew the authorization.
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Pre-billing & claim generation
After a provider, like a BCBA, renders a service, the billing team at the clinic will submit a claim to the insurance payer.Balaji (Bala) Ramani, Vice President of Business Development at Plutus Health, says that a BCBA or RBT will take thorough session notes that will help the billing team create a claim. Bala is a senior management sales professional with several years of experience in building successful Marketing and Sales teams.
Balaji (Bala) Ramani, Vice President of Business Development at Plutus Health Inc. "In an ideal world, the provider is writing detailed session notes using a template that includes categories for every type of information the payer needs," he says. "For example, they should write the start and end time of the session and describe their basic interventions, among other important details."
After a provider finishes their session notes, the billing team generates an insurance claim for the session.
Here's a summary of the most important parts of a claim that the billing team verifies before submitting it to the relevant insurance payer:
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Authorization and units
The pre-billing team makes sure that the child is still within the amount of units that the insurance had authorized. If they find that the provider used more units than the authorization allows, the pre-billing team discusses the claim with the provider and adjusts the units(for MUE) before submitting the claim. Modifiers and CPT codes
Each claim must include a Current Procedural Terminology (CPT) code and modifier to describe the specific service and the credentials of the rendering provider.The pre-billing team will double-check that the CPT code and modifier are correct based on the payer's requirements and the provider's session notes.
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Provider credentials
Some insurance providers allow RBTs to perform only certain services. The pre-billing team will ensure that the provider credentials align with the level of service and the payer's requirements. -
Specific payer Session note requirements
Session note requirements change by the payer. The pre-billing team will double-check that the Session notes meet the specific payer's needs.Submitting Session notes as part of a claim is usually not mandatory. However, many ABA experts recommend that clinics maintain thorough and complete records because payers often require Session notes during either claim audits or PPRU reviews.
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Claim submission, clearinghouse, and insurance processing
After the pre-billing team prepares the claim, they submit it to the insurance company.Bala describes the next step:
"After validating each claim during the pre-billing process, the biller will submit the claim to the payer. First, it goes to the clearinghouse linked to the billing system, where the clearinghouse has its own set of scrubbers, and it checks the claim for any blatant errors. If the clearinghouse approves the claim, they send it to the payer."
After the payer receives the claim, they run it through their system to check for errors. After this point, the payer will either send a payment or a denial based on their usual payment cycle (varies by each payer).
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Denial management & reconciliation
“The industry standard is to achieve a 95% or greater acceptance rate, meaning 5% or less of your claims turn into denials,” says Bala. “But even the best teams will receive a denial — as no one has a 100% payment rate. At that stage, it’s up to your RCM team to go through a denial management process to try and fight the Denials and get it paid, to ultimately reconcile the funds.”Denial management involves reviewing denied claims to identify easily correctable issues. For example, a denial management team can identify common problems like misspelled names or incorrect CPT codes and resubmit the claim. Denial management also means establishing processes to avoid submitting bad claims, like using software to flag eligibility and authorization issues before submitting the claim.
How to Bill Insurance as a BCBA vs. an RBT
BCBAs and RBTs may have to use different modifiers based on the type of the services and the payer’s specific requirements. Certain payers do not separate RBT and BCBA services. Instead, they include RBT services as part of their supervising BCBA's claim.
The difference between billing insurance as an RBT or a BCBA depends entirely on the payer.
“Every insurance company has its own guidelines that we must follow,” Price says. “Most insurance companies only accept claims for services rendered by a BCBA or an RBT with supervision from a BCBA. In both cases, we will submit a claim for the BCBA, with any RBT services lumped into that claim.”
However, Price also notes that certain payers, like Tricare, do accept and require RBT services to be billed separately. In those cases, you must adjust the modifier codes to communicate that you are billing exclusively for RBTs services.
ABA CPT Codes
ABA CPT codes are a set of standardized terms that describe specific ABA services and treatments. As of 2024, there are 10 CPT codes that describe client assessment tasks, treatments, and interventions. Providers should enter the CPT codes on insurance claims.
The American Medical Association (AMA) uses CPT codes to create a uniform language for providers to describe medical treatments and services. The purpose of CPT codes is to streamline insurance claims and quickly communicate basic services to different stakeholders.
The two code categories are CPT I codes and CPT III codes. CPT I codes describe routine services, and CPT III codes describe new and emerging technology.
Bala says that the process of selecting ABA CPT Codes is straightforward.
“There are only 10 CPT Codes in ABA,” he says. “Other medical specialties, like cardiology, ER or surgery, have hundreds of codes that the provider must select from. One misplaced number in the five-digit CPT code might completely change the code’s meaning and lead to a denial. Luckily, the low number of CPT codes means it’s relatively easy to avoid this issue in ABA.”
Here's a brief overview of ABA CPT codes as of 2024 from the ABA Coding Coalition. All payers, including Medicaid, use these CPT codes.
ABA Billing Modifiers
ABA billing modifiers describe the provider’s credentials and are critical for insurance claims. ABA modifiers can be complex because each payer and state has unique requirements. Some payers also use modifiers to indicate who was present at the session.
In ABA, the modifiers usually reflect an RBT, a BCBA, or a BCBA-D.
“Although CPT coding in ABA is simple, adding in the right modifier can be tricky,” Bala says.
“That’s because each payer and each state have specific ways to use a modifier.”
Modifiers vary by state, payer, type of service, and provider credentials.
"For instance,” Bala says, “the modifier in Washington State will differ from that in California, even if the service and provider credentials are identical. Additionally, the session's location and the specific individuals present during the session also influence the modifier.”
Here's a summary of the four most common ABA billing modifiers. Note that different payers have different modifier requirements, and this list is not exhaustive.
- HO modifier: The HO modifier denotes that an ABA supervisor, like a BCBA, rendered the services that the CPT code indicates.
- HN modifier: The HN modifier describes that a trained provider with a bachelor’s degree and a BCBA, rendered the services.
- HP modifier: The HP modifier describes a doctoral-level provider, like a BCBA-D.
- HM modifier: The HM modifier denotes behavior technicians or anyone without a bachelor’s degree.
ABA Billing Guidelines and Best Practices
ABA billing best practices include establishing a strong front-end and pre-billing process. Experts also strongly recommend investing in practice management software to automate tedious tasks. Other guidelines include hiring experts who know your state and payer guidelines.
Here's a list of ABA billing guidelines and best practices from our RCM and ABA billing experts:
Challenges of ABA Billing
The major challenge of ABA billing is the lack of standardization. Different payers and states have different requirements, which complicates claim submission. Also, prior-authorizations and credentials are key but require time and effort.
Understanding Revenue Cycle Management for ABA Therapy
Revenue cycle management (RCM) in ABA is the process of managing your clinic’s entire finances. Optimizing RCM improves your cash flow and the patient experience. Experts recommend outsourcing RCM to a trusted expert.
Revenue cycle management (RCM) involves managing all aspects of a clinic's operations to optimize its finances, from client intake to ABA billing tasks like submitting claims and denial management. Experts stress that the different steps in RCM all affect the process as a whole.
“ABA billing is just one component within a clinic’s broader RCM framework,” says Mark Phan, a senior Client Success Manager at Plutus Health Inc. with nearly a decade of experience in ABA and RCM. “Unfortunately, many billers approach ABA billing without considering its place in the larger RCM cycle.”
Mark says it’s critical to outsource your billing to an expert team that will manage your RCM end-to-end. He says that the best vendors do not just want to reduce your denials; they want to help you grow your clinic.
“It’s not just about partnering with someone who can help you keep the lights on,” he says. “Look for a partner capable of driving business expansion. For example, the best vendors will strategically use key performance indicators (KPIs) and other tools to forecast revenue changes. They will also understand how to make meaningful adjustments to increase revenue and facilitate long-term growth.”
How To Streamline Your ABA Billing
Streamline your ABA billing by teaming up with the RCM experts at Plutus Health. Recognized for top-tier outcomes, Plutus Health uses cutting-edge innovative analytics for personalized solutions. Plutus Health ensures your RCM not only supports your clinic but also helps it thrive and succeed.
Plutus Health leads the industry in optimizing RCM for ABA clinics of all sizes. Our expert team includes experienced ABA billers who have mastered the ins and outs of ABA billing across states and payers. Our ABA experts and certified coders stay updated on changing requirements, codes, and more, ensuring your cash flow and client services never falter due to evolving payer demands.
In addition to billing, Plutus Health’s end-to-end RCM services cover every aspect of your workflow, from front-end check-in to denials management. Plutus Health’s ABA practice management software – Artemis ABA (www.artemisaba.com) is provider-friendly and features customizable data collection tools, session note templates, and more.
ABA clinic owners, BCBAs, and RBTs can thrive working with Plutus Health.
ABA Billing FAQs
Find answers to common ABA Billing FAQs, such as how to bill for virtual visits and multiple therapists. Also, find out how to bill for providers with different credentials and distinct types of sessions.
How Do You Bill Multiple Therapists for the Same Client?
To bill multiple therapists for the same client, each therapist documents their services separately for each session they conduct with the client. Then, the billing team submits claims for each session to the relevant payer.
How Do You Bill Virtual ABA Visits?
Billing for virtual ABA visits is like billing for an in-person session. One difference is that you add a specific modifier for remote sessions. It is important to ensure the payer covers virtual services, and you should follow any telehealth guidelines.
How Do We Bill for an ABA Supervisor or Manager?
Billing for an ABA supervisor or manager usually involves adding a specific modifier to the CPT code. For example, many payers use the HO modifier for ABA supervisors. It’s important to check the guidelines for each payer.
Is It Possible to Bill for the Supervisor and Behavior Technician at the Same Time?
If both the supervisor and behavior technician provide the service, it is usually possible to bill for both. Many payers use a specific modifier to describe this situation. However, be sure to review each payer’s billing guidelines.
Can You Bill for Supervision and Group Services at the Same Time?
You typically cannot bill for supervision and group services simultaneously. Supervision services involve oversight provided by a qualified supervisor, like a BCBA, and group services involve sessions with multiple clients. It is essential to check each payer's guidelines.
