Finding Common Ground with the Insurer
originally published in the (Florida Assoc of Behavior Analysts) FABA Observer Summer 2017
By Matt Briere-Saltis
Insurance Companies and ABA providers often find themselves in an ostensibly unenviable relationship. One side is seeking to mitigate their financial investment while the other attempts to mitigate the effects of an often lifelong, debilitating disorder. And yet the two coexist every day, discussing authorizations for ABA treatment, often debating the question of medical necessity.
Every funding source of ABA has a slightly nuanced understanding of what is medically necessary. Some definitions are shaped by very informed and sincere men and women with appropriate medical, psychological, educational, and behavior analytic experience. Some, unfortunately, are shaped by borrowed legal precedent and misguided priorities. And most fall somewhere in the middle, generally accepting that ABA is appropriate to treat deficits with Activities of Daily Living, Communication, Problem Behavior, Social Skills, Language Building, etc.. Some will require that no educational targets be set, others will deny coverage for vocational skills training, and others still will not fund in the absence of notable problem behavior.
It is important to be prepared to experience the full gamut of definitions when you are interacting with funding sources, which often are private insurance agencies. Insurance agencies typically can give some information electronically or over the phone regarding general policies on what they define as medically necessary for ABA therapy. But another funding source that’s important to consider is the self-pay family. They may have a different understanding of what is medically necessary, and it may be a vital step for you to have the same type of discussion regarding ethical standards of treatment with a parent as you might with an insurance representative.
The discovery of common ground also involves having the right documentation. Again most insurance providers that fund a large number of ABA plans will have designated forms, and information that they request. There may also be requests for additional information after the original forms have been submitted. The individual that is able to submit this documentation in a timely and accurate manner will always have a leg up.
Ultimately, success when communicating with insurers comes down to pleasant persistence. And that often manifests as plenty of phone calls, emails, faxes, and face palms. But communication is important, and it can sometimes be tempting to multitask while communicating, especially when there is graphing to be done. But it can also detract from the conversation. Being prepared and being present will likely reduce the number of future phone calls. Being pleasant is just a good thing to shoot for.
Matt Briere-Saltis is a Board Certified Behavior Analyst (BCBA), certified PCM instructor, and certified PCIT therapist. Matt has served the last two years as the Clinical Program Manager for Great Strides’ Outpatient department. The Outpatient department serves clients out in the community, in both public and private schools as well as home based programs. Matt has worked in the field of Behavioral Health for a little over a decade now, having worked in hospital settings, group homes, clinics, and as an expert witness. In addition to providing training and supervision to staff members at Great Stride, and administrative support to the Great Strides Leadership team, Matt has written and been interviewed for multiple publications, including the FABA Observer.
Did You Know? ABA therapy for Down Syndrome Covered by Insurance
Did you know that the Florida Senate passed a House Bill in March of 2016 to require insurance companies to pay for ABA therapy for individuals with Down Syndrome to the same degree as for individuals with Autism? Most insurance plans began including this coverage at the start of their plan year, which for many was January 2017. This means that your child could receive 20-30 hours per week of interventions to improve your child’s and family’s quality of life. Have a young child? Contact us about our Early Intervention Preschool Program and to find out more on insurance coverage for ABA therapy!