Applied Behavior Analysis, or ABA, has long been known to be an effective treatment for children with autism. Once a parent decides to pursue this form of treatment for their child, the almost universal next question is, “How are we going to pay for it?”
We are fortunate here in Indiana to have a very strong mandate that makes ABA therapy more accessible as it is covered under many health insurance policies. The process of determining coverage as it relates to autism therapies, and ABA specifically, can be very daunting for a family.
Debbie Ide, Cornerstone Autism Center’s Chief Operating Officer, takes much of that problem off your hands. She and her experienced staff make the calls to insurance companies to verify coverage, seek the necessary authorizations and file all claims with regards to the services that are provided at their facilities.
I asked Debbie Ide some questions to learn a little more about managing this part of autism.
Jarrad: Debbie, what does occupational therapy, speech, dietary, ABA or other interventions for autism cost out of pocket?
Debbie: Costs for intervention are dependent on the provider and the type of health coverage that the individual has. OT/PT/ST sessions are usually billed per hour, and are oftentimes capped at 20 visits per year. ABA therapy, which is provided 20-40 hours per week, can be very costly due to the intense nature of the intervention and would be virtually unattainable without insurance coverage.
J: What does insurance pay for?
Debbie: With regards to our kiddos, health insurance will often pay for occupational therapy, physical therapy, speech therapy, medications and ABA therapy if they are medically necessary and prescribed by a physician.
J: What lingo (codes, acronyms, terms, etc) may confuse families who deal with the insurance for their child?
Debbie: Almost everything having to do with insurance companies can be confusing and intimidating! That is why Cornerstone has a team devoted to this task and takes this burden off the families’ shoulders and handles every aspect of the insurance billing process. Perhaps the single-most area of confusion for families is understanding what type of policy they have. The mandate only applies to fully-insured plans in the state of Indiana. If their plan is self-funded, or issued by another state, then our state mandate does not apply. With more and more states adopting mandates however, there are many more options than there were just a few years ago. Our staff knows what questions to ask and how to get to the bottom of what is covered and what is not.
J: How long can a claim take to be approved?
Debbie: Authorizations for ABA therapy can take up to 2 weeks to receive. Once we file a claim for ABA therapy, the insurance company has up to 45 days to respond.
J: What are common mistakes that make a claim take longer?
Debbie: Mistakes, if made, usually result in a claim denial and then a corrected claim must be submitted, something our staff would handle. Claims processors are human, and with that comes human error, so many delays are caused by things outside of our control at the insurance company. Our staff takes notice when a claim has been outstanding for too long and calls are made to determine the cause of delay and remedy the situation.
J: Are there other types of coverage that families should know about?
Debbie: Children’s Special Health Care Services will provide some coverage for ABA therapy if the individual qualifies. Qualifications are both financial and medical in nature. Children’s is a supplemental policy only and is limited to 20 hours per week, and a maximum of $10K per year.
J: What things will insurance companies constantly want updates on?
Debbie: Insurance companies will want to see progress notes and/or treatment plans in order to continue to authorize services. The mandate stipulates that insurance companies can ask for updates every six months. Cornerstone provides all documentation requested by insurance companies.
August 6, 2012, cornerstoneac