ABA Insurance Denials: What to Do When Insurance Says “No!”

Maintaining a healthy revenue stream is vital to covering costs, staffing and resources needed to run a successful ABA organization. However, the complexities surrounding claims denials and appeals can hamper a healthy cash flow for many practices.

In BHCOE’s webinar Denials 101: What You Need to Know About ABA Denials, Appeals, and More, ABA industry experts share best practices for navigating the denials and appeals process, and mitigating the risk of future denials.

As a relatively newer field, ABA has some unique challenges when it comes to billing and claims denials. The denial codes for ABA aren’t standardized across carriers, so it takes a lot of manpower to identify denials, understand why claims were denied, and get them fixed. Further, sometimes carriers use more than one denial code and each carrier has its own appeals process.

Says webinar panelist Bryce Miler, contracts director with Trumpet Behavioral Health, “The entire ABA industry is advocating for standardized claims processes to help improve the appeal workflows. Until then it’s important that your billers know the nuances and differences between the carriers.”

Below, we recap key points from the webinar including a checklist for requesting adjustments and submitting appeals.

Control the Things You Can Control
The first step to minimizing denials is to ensure you are billing as accurately as possible. “Accurate billing goes a long way because often you’ll see multiple denials and realize the error is on your end,” says Miler.

Another challenge in ABA is knowing which carrier to bill. Clients may have medical coverage through one plan and mental health coverage through another. On top of that, mental health claims may be handled by a third-party administrator in order to get paid and yet another entity may handle pre-authorizations. It’s also vital to track all carrier-specific rules and billing requirements. For example, know whether the carrier uses CPT codes or HCPCS codes and who is the billing provider and rendering provider.

Using credentialed providers is also a sound business practice. Keep a written record of the carrier’s acknowledgement that the provider is approved and ready to go. It’s also important to bill services that require pre-authorization correctly with viable authorization numbers on the billing. “Sometimes providers bill before they have the authorization number in hand because it can sometimes take a while to get that.” notes Miler. “But billing without an authorization number will often result in a denial that you have to fight.”

“In order to get paid, you need to understand which network you need to be in to get paid as ‘in-network’ and you also need to know where your claims should be sent,” says Miler. “Agreeing to bill for a client when you’re not in network can be risky and challenging. Usually plans will only approve it if they don’t have enough ABA providers in a given area.”

Stop the Bleeding
Once your internal systems are optimized to minimize the number of denials, it’s important to quickly identify denials and work to get them corrected. While a single denial with an individual member is usually a straightforward issue to resolve, global carrier issues across multiple members or multiple denials for a single member can be more complex. Often the carrier is not aware of the denial, so it’s important to inform your provider representative as soon as possible.

Global issues that can cause denials include:

  • Incorrect Medically Unlikely Edit (MUE) caps on services provided per day
  • Incorrect denials for telehealth claims that were billed correctly
  • Out-of-network benefits paid when your BCBA is credentialed
  • Rates not allowed as agreed to in your contract
  • Claims incorrectly denied as duplicates, such as paying only one code per date of service

Julie Kornack, Vice President of Government Relations, Center for Autism and Related Disorders, talked in depth about MUEs and some of the challenges around denials related to MUEs. MUEs are intended to flag potential fraud and/or billing errors by identifying the maximum number of units a provider is likely to report for a specific code in a single day for an individual patient. MUEs are not intended to limit medically necessary treatment. MUEs also don’t eliminate the prohibition on quantitative treatment limits established by the Mental Health Parity and Addiction Equity Act.

Providers who encounter claims denials on the basis that a service exceeds the MUE should appeal them and alert the ABA Billing Codes Commission when claims denials are upheld.

A claim denied as a duplicate can occur when a provider concurrently files for 97155 (behavior analyst) and 97153 (behavior technician). The payer controls whether it allows concurrent billing of the two codes. “When you’re negotiating your rate with that payer, if they won’t pay for both your behavior technologist and behavior analyst to deliver a service concurrently, you probably want to try to negotiate a higher rate to capture the cost of the unpaid employee,” advises Kornack.

Kornack further notes that for a claim to be considered a duplicate, it must have ALL of the following eight elements in common with another claim:

  • HIC number (Medicare patient ID)
  • Provider number
  • “From” date of service
  • “Through” date of service
  • Type of service
  • Procedure code
  • Place of service
  • Billed amount

Implement an Intake Protocol
Establishing an intake review protocol can help ensure claims for new clients are paid. Identify staff, such as collectors, billers and accounts receivable employees, to look for denials for initial intakes under 97151 or any other HCPCS codes you use. When an initial intake claim is denied, it is often because the wrong entity is billed or there are benefit issues.

“If you can catch an issue on the intake and get it corrected, you can potentially stop a couple of months’ worth of denials,” notes Bryce.

To learn more about managing claims denials and appeals, listen to the full webinar and download the below checklist on how to ask for adjustments and submit appeals.

Download the Checklist

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