Welcome back to our blog series tailored for BCBA entrepreneurs embarking on the journey of opening their own ABA therapy clinics. You’ve come a long way since hanging out your shingle: after coming up with your new clinic’s name, you already have started payor contracting, credentialing, and enrollment. Congratulations – you’re ready to start seeing clients! All you have to do is start administering services and billing your in-network payors.
Not so fast!
Today, we will explore the crucial process of obtaining prior authorization from payors before beginning treatment with new patients. This step is vital for ensuring that the services you provide are covered under the client’s health insurance plan, thereby securing your clinic’s revenue and facilitating effective care delivery.
Understanding Prior Authorization
Prior authorization is a requirement that your client’s insurance provider must approve certain medical services before you perform them. For ABA therapy, this is particularly important due to the high costs associated with long-term treatment plans. Prior authorization helps ensure that the proposed services are covered under the client’s current health insurance policy and are medically necessary.
Step-by-Step Guide to the Prior Authorization Process
- Verify Insurance Coverage: Before initiating any treatment, verify the client’s insurance coverage. Determine if the insurance plan covers ABA therapy and to what extent, including any caps on the number of sessions or total coverage amount.
- Gather Required Documentation: Collect all necessary documentation to support the prior authorization request. This typically includes:
- Client’s diagnostic information confirming an autism spectrum disorder diagnosis.
- Proposed treatment plan outlining the goals and duration of therapy.
- Clinical notes and assessments that justify the need for ABA therapy.
- Submit the Authorization Request: Submit the prior authorization request form to the insurance company. Ensure that all fields are accurately completed to avoid delays. Some insurers require submission via specific platforms or portals, so it’s important to follow the payor’s prescribed submission process.
- Follow Up Regularly: Insurance providers may take anywhere from a few days to several weeks to process a prior authorization request. Regular follow-ups can ensure your request is being processed and can help expedite approval. Be prepared to provide additional information if the insurance company requires further clarification.
- Communicate with the Client’s Family: Keep the client’s family informed throughout the process. Clear communication about the status of the authorization and any potential delays is crucial for maintaining trust and managing expectations.
- Receive and Review the Authorization: Once approved, you will receive an authorization notice detailing the approved number of sessions or coverage amount. Review this document carefully to ensure that it matches the requested treatment plan. If there are discrepancies, contact the insurer immediately to address them.
- Document Everything: Keep detailed records of all communications with the insurance company, including dates of submissions, follow-ups, and copies of the authorization. This documentation will be invaluable in case of disputes or audits.
Tips for Streamlining the Prior Authorization Process
- Educate Your Team: Ensure that all team members involved in the prior authorization process understand the steps and requirements. This includes training on how to complete forms accurately and manage follow-ups effectively.
- Utilize Technology: Consider using practice management software that includes features to help manage prior authorizations, track the status of pending requests, and store client insurance information securely.
- Build Relationships with Insurers: Establishing good relationships with insurance providers can facilitate smoother communications and quicker resolutions of issues that may arise during the prior authorization process.
Conclusion
Obtaining prior authorization is a critical step in the process of providing ABA therapy. While it can be complex and time-consuming, understanding and efficiently managing this process is essential for the financial stability of your clinic and the uninterrupted care of your clients. Stay proactive, organized, and patient—qualities that are as important in business as they are in therapy.