This comparison draws in part from “Appealing Payer Denials: Tips from the Insurance & Medicaid SIG” by Craig Domanski, M.A., BCBA (BehaviorLive), and extends it with peer-reviewed research from our library of 27,900+ ABA research articles. The decision framework, BACB ethics code references, and cross-links below are synthesized by Behaviorist Book Club.
View the original presentation →One of the most consequential decisions a behavior analyst makes is not just what intervention to use, but how to approach the clinical question in the first place. For appealing payer denials: tips from the insurance & medicaid sig, the difference between an evidence-based, individualized approach and a traditional, protocol-driven one can significantly impact outcomes.
This guide lays out the key factors side by side to support your clinical decision-making.
| Factor | Evidence-Based Approach | Traditional Approach |
|---|---|---|
| Immediate client impact | Accepting: Client receives reduced or no services, potentially losing critical treatment hours | Appealing: Client's access to medically necessary services is preserved or restored if appeal succeeds |
| Clinical message to payer | Accepting: Communicates that the original request was not truly necessary | Appealing: Asserts the clinician's professional judgment about medical necessity |
| Administrative burden | Accepting: Minimal time investment but potential for ongoing authorization fights | Appealing: Significant time investment per appeal but may improve future authorization outcomes |
| Ethical compliance | Accepting: May fail to meet advocacy obligations under the BACB Ethics Code | Appealing: Fulfills the obligation to advocate for client access to effective treatment |
| Systemic impact | Accepting: Enables increasingly aggressive payer denial practices over time | Appealing: Establishes clinical standards that influence payer authorization practices |
| Family empowerment | Accepting: Family may not know they had the right to challenge the determination | Appealing: Family learns about their rights and develops advocacy skills |
| Documentation quality | Accepting: No incentive to improve clinical documentation practices | Appealing: Appeal preparation improves overall documentation quality and clinical thinking |
| Professional development | Accepting: Insurance navigation skills remain undeveloped | Appealing: Builds expertise that benefits all future clients |
The ABA Clubhouse has 60+ on-demand CEUs including ethics, supervision, and clinical topics like this one. Plus a new live CEU every Wednesday.
Use this framework when approaching appealing payer denials: tips from the insurance & medicaid sig in your practice:
Does the data support a need for intervention? Is there a meaningful impact on the individual's quality of life, safety, or access to reinforcement?
YES → Proceed to assessment NO → Document reasoning, monitor
A functional assessment should guide intervention selection. Avoid defaulting to standard protocols without individual analysis. Consider environmental variables, setting events, and private events.
YES → Select evidence-based approach matched to function NO → Complete assessment first
Goals should be co-developed. Assent and informed consent are ethical requirements. The individual's preferences and values matter in selecting both goals and methods.
YES → Proceed with collaborative plan NO → Engage in shared decision-making
This course covers the clinical and ethical dimensions in detail with structured learning objectives and CEU credit.
Appealing Payer Denials: Tips from the Insurance & Medicaid SIG — Craig Domanski · 1 BACB Ethics CEUs · $30
Take This Course →We extended this decision guide with research from our library — dig into the peer-reviewed studies behind each approach, in plain-English summaries written for BCBAs.
256 research articles with practitioner takeaways
233 research articles with practitioner takeaways
189 research articles with practitioner takeaways
1 BACB Ethics CEUs · $30 · BehaviorLive
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All behavior-analytic intervention is individualized. The information on this page is for educational purposes and does not constitute clinical advice. Treatment decisions should be informed by the best available published research, individualized assessment, and obtained with the informed consent of the client or their legal guardian. Behavior analysts are responsible for practicing within the boundaries of their competence and adhering to the BACB Ethics Code for Behavior Analysts.