The tension between clinical best practices in behavioral assessment and the realities of insurance and Medicaid authorization requirements represents one of the most consequential challenges facing behavior analysts in contemporary practice. This gap directly affects the quality of services that clients receive, the financial sustainability of ABA organizations, the professional satisfaction and ethical wellbeing of practitioners, and the broader credibility of the field.
Provider: BehaviorLive — via Council of Autism Service Providers
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Join Free →While both ABA providers and funders of ABA treatment agree that comprehensive assessment and ongoing reassessment is essential for effective treatment planning and implementation, a great deal of variability and divergence exist between what constitutes a quality assessment and how long it takes to complete. For too long, payor policy and assessment requirements have shaped our clinical practice, often resulting in delivering countless hours of non-billable services and detracting from the individual needs of the client. Over the past two years, the Insurance and Medicaid Special Interest Group has been working on a project involving the Assessment/Reassessment CPT Codes (97151, H0031) with the goal of documenting the work required to complete a comprehensive and individualized initial assessment/treatment plans and subsequent updates. Through the information gathered from two recent surveys, we have gained a greater understanding of the experiences both CASP members and other providers are experiencing with these codes. Results indicate that many payor policies do not align with actual clinical practice, and often clinicians are modifying their assessment practices based on payor rules rather than client needs. Specific challenges with the 97151 and related codes include insufficient hours authorized, daily MUE limitations, large numbers of unbillable/unbilled service hours, and multiple co-pays for families. The presenters will discuss the importance of communicating these realities to their payors through authorization requests, appeals (both insufficient hours and MUE limitations), and billing practices, as well as the importance of describing why clinical recommendations are medically necessary. Presenters will share their expertise, experience, answer questions, and encourage open discussion. Ultimately, we are hoping to bring a common understanding and consensus among the ABA community, insurance companies, and other third-party payers. Please contact Paula Pompa-Craven at Paula.Pompa-Craven@essc.org should you have any APA questions or concerns!
| Certification Body | Credits | Type |
|---|---|---|
| BACB® | 1 | Ethics |
| APA | 0 | — |
| COA | 1 | — |
Andi Waks is the Director of Client Services at Autism Partnership. She began working with children with autism spectrum disorder in the late 1970s at UCLA on the Young Autism Project, where she served as a Senior Therapist, Research Assistant, and Teaching Assistant. Andi has worked with Drs. Leaf and McEachin on the Young Autism Project, the Behavior Therapy and Learning Center, Straight Talk, and Autism Partnership. She earned her master's degree in General Psychology at Pepperdine University and returned to school to pursue a law degree. She practiced special education law, representing families of children with ASD, before returning to Autism Partnership full-time. She consults with families and school districts both locally and nationally and currently serves on the Board of Autism Partnership Foundation.
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280 research articles with practitioner takeaways
279 research articles with practitioner takeaways
252 research articles with practitioner takeaways
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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.