Working with Insurers
In our experience, the most important lesson is that to be successful in this business, you must be more tenacious and persistent than the third-party payors. When a third-party payor denies prior authorization for treatment of a child with severe destructive behavior, or they offer a reimbursement rate that falls well short of that required to deliver the service, you should pursue all possible strategies to overturn a denial, negotiate an acceptable rate, or both.
Single-Case Agreements
Ideally, the program will contract with payors to provide services to their members as an in-network provider. Given that the program will be providing unique services and may serve patients from a wide geographic area, the program may not be in network for some patients. In these cases, a single-case agreement may be necessary if the program or providers in the program do not have a contract with a patient’s insurance company. A single-case agreement is a contract between a program or provider and an insurance company that allows the program or provider to deliver services to an individual patient as if the provider or program were in-network. A single-case agreement allows a patient to access a specialty service that is not available in network or not available within a reasonable distance from the patient, contains out-of-pocket costs to the patient, and preserves the cost benefits the insurance company derives from in-network providers.
Prior Authorization
Prior authorization is the process by which an insurance company determines that a treatment is medically necessary. Prior authorization is typically necessary given the specialized nature of a severe behavior program. The risk of not obtaining prior authorization before you deliver services is that the insurance company may not pay for your services. Obtaining prior authorization does not guarantee you will get paid, but it increases the probability greatly. Expect to devote considerable time for the prior authorization, billing, and collection processes. Your insurance/authorization person will organize the required information that the insurance company requests.
Peer-to-peer Review
Some companies have a process for peer-to-peer review. Your insurance and authorizations specialist should find out whether the company has such a process in case of denials. If the company is self-insured, encourage the caregiver to contact their human resources department. Self-insured companies can opt to pay for the services. If the company is not self-insured, the insured can request an external review after the caregiver has exhausted the internal appeal options through their insurance company. The final denial letter should have information about the external-review process.
Alternatives to Insurance Funding
Up to this point, the focus of this document has been on a severe behavior program that is funded primarily or exclusively on a fee-for-service basis by billing health insurers or Medicaid for the services. There are, of course, alternatives to this funding mechanism. One alternative would be to develop the service as a school-based program and charge a tuition to the individual’s local school system for the services delivered. The severe behavior program the authors developed at the Marcus Autism Center in Atlanta included a school program and many children in the program spent ½ of the day in a classroom, for which they charged a tuition to the school system, and they spent the other ½ of their day in ABA sessions, for which they changed insurance or Medicaid. Another potential source of funding for a severe behavior program would be to seek state funding for the program through the state legislature.
