Top 5 Denials in ABA Billing and How to Fix Them

Successful ABA practices understand the need to reduce claim denials. Insurance denials harm cash flow, hampering an ABA practice’s ability to pay for staff, resources, rent, and other overhead expenses. Even when a Denial is correctable, correcting, and resubmitting claim costs valuable time and resources. 

As such, understanding what claims are likely to be denied and how to respond is crucial. Here are the top five pitfalls to avoid in ABA billing and reducing denials. 

Eligibility Expiration

Even when the client is signed up to an ABA-friendly plan, enrolled individuals may unknowingly have passed an expiration date. For example, many states require coverage up till an individual is 18 years old. And some states cut requirements off as low as six years of age. In such cases, there is a good chance the insurer will take the minimum age legally available to them. 

Solve these cases with careful attention to detail. Before administering a service, your office needs to ensure that the client is eligible. Proceed only once your team has confirmed the insurer covers the service. 

The Client’s Plan does not cover services

While most states require ABA coverage, only some plans need to provide that coverage. For example, several states have no ABA requirements for employer-sponsored plans with fewer than 50 employees. 

Regardless of their child’s needs, if a parent has a health plan with no ABA coverage, their insurer will deny claims. Employing a reliable billing system helps identify easily overlooked aspects that can increase claim acceptance rates. 

Failure to get a referral from a Health Professional

States only mandates coverage for medically necessary conditions. When familiar with local requirements, establishing medical necessity is simple. Ensure the child has seen a certified professional that the state recognizes as a competent authority. Next, get a written referral from this professional and include it in the Prior-Authorization request you send to the insurer. 

Change in Network Coverage

Some state laws demand insurers provide a good network of coverage for their members. Despite these efforts, insurers will often change what services they cover without the plan holder knowing. This practice frequently results in a customer’s health plan no longer offering adequate coverage. 

ABA therapy providers have a responsibility to establish coverage before offering services. However, many offices will note that the service was covered last time for a returning client and fail to check for updates. This shortcut can negatively impact the relationship between a client and the ABA provider. Be consistent with coverage inspection to avoid time-costly denials. 

Mistakes in Documentation

Simple errors, such as typos, frequently result in denials. While these errors are fixable, they often take a frustrating amount of time to handle. Additionally, they force ABA providers to spend extra time and labour correcting the mistake. With proper use of technology, providers can streamline the administration process and avoid such manual errors. 

General Tips to Create Accepted Insurance Claims

The level of detail insurers provides for denials vary. Some errors come with annotations, while others lack comments. Inexperienced staff members frequently write off these denials. Make sure you have an online workspace that analyses and categorizes different mistakes. This process is invaluable at ensuring consistency across your staff and consistency of response to each type of denial.

Your practice must understand what mistakes are most common and deploy suitable workers to fix them. For example, assign one employee to specialize and search for minor errors such as typos. Quickly removing these denials frees up the remainder of your team to focus on more significant errors. 

Plutus Health makes it easier for ABA practices to avoid denials. We use a detailed denials management strategy for each ABA customer. We find out why the claim was denied, and we quickly correct the issue — preventing the denial from reappearing in the future. If you struggle with billing, collections, and denial management, our expert team takes care to get the fastest reimbursement possible and increase your practice’s cash flow and performance.

Key Takeaways

1. Clients inadvertently pass a plan’s expiration date.  

2. A plan does not cover whatever service the practice has performed. 

3. Medical necessity is not established or Prior-Authorization not sent to the insurer. 

4. Network coverage changes without the member’s knowledge.

5. Administration errors cause delays in the claim adjudication process.

6. Section your team into specialized units that can quickly act on specific denials.