This comparison draws in part from “**Real World Assessment Challenges: The Gap Between Clinical Best Practices and Payor Practices” by Andi Waks, J.D. (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 **real world assessment challenges: the gap between clinical best practices and payor practices, 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 |
|---|---|---|
| Assessment Scope Determination | Scope defined by payor's standard authorization template regardless of case complexity | Scope determined by clinical evaluation of presenting concerns, complexity, and assessment questions |
| Authorization Request Approach | Requests match payor's typical approval amount to avoid denials | Requests reflect clinical determination of need with documented medical necessity rationale |
| Treatment Plan Foundation | Treatment plans built on whatever data could be gathered within authorized hours, potentially incomplete | Treatment plans built on comprehensive assessment data adequate to support clinical recommendations |
| Non-Billable Services | Significant non-billable assessment time absorbed by provider to compensate for insufficient authorization | Assessment time is appropriately documented and billed, with additional authorization requested when needed |
| Ethical Alignment | Potential tension with Ethics Code requirements for adequate assessment and effective treatment | Aligned with Ethics Code requirements for comprehensive assessment and clinical integrity |
| Long-Term Outcomes | Risk of ineffective treatment due to incomplete assessment, potentially increasing total service utilization | More effective treatment targeting based on thorough assessment, potentially reducing long-term service needs |
| Systemic Impact | Enables continued payor practices that limit assessment below clinically appropriate levels | Creates documentation trail supporting advocacy for improved payor policies and adequate authorization |
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 **real world assessment challenges: the gap between clinical best practices and payor practices 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.
**Real World Assessment Challenges: The Gap Between Clinical Best Practices and Payor Practices — Andi Waks · 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.
280 research articles with practitioner takeaways
279 research articles with practitioner takeaways
252 research articles with practitioner takeaways
1 BACB Ethics CEUs · $30 · BehaviorLive
Research-backed educational guide
Research-backed answers for behavior analysts
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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.