Mental Health & Autism Health Project How do we Help Autism Providers?
We understand that as providers, your top priority is helping the children you work with! Wrangling with insurance companies consumes valuable time and we are here to help. We assist healthcare providers in navigating the insurance maze so that you can do what you’re best at—help children!
How Do I Become In-Network?
Forty-four states states (and D.C. and USVI) have already passed autism insurance reform laws that require health plans to provide ABA therapy, speech therapy and other autism-related treatments. Because of these laws, thousands of families who have a child with autism (1 in 68) are seeking out treatments for their children. If a family has a choice between a provider who accepts insurance and one who does not, the choice is simple. Growing your business and supporting autism families requires providers to do the footwork to become in-network. In addition, once you are in-network the billing process should be easier.
The challenges involved in becoming an in-network provider can be overwhelming. It involves a fair amount of paperwork, follow-through and persistence. We have connections and relationships at the all the major health plans. We directly assist providers from start-to-finish in getting into plan networks. We offer discounted rates to non-profit organizations. Contact us for assistance.
What Services and Treatments Can Be Covered?
Intensive behavior therapy, speech therapy, group social skill language therapy, occupational therapy, and physical therapy are all medically necessary treatments, and are covered benefits under many state autism mandates. With the passage of the Affordable Care Act, fully-funded plans in all states must now offer habilitative care in parity with rehabilitative care. That means that they must offer at least as many sessions of these therapies as they offer for rehabilitation, and they should no longer be denying care because the condition is a developmental disability. Most health insurers know this, and will approve these treatments when you call them on it. If not, it is an easy battle to win by simply citing the law! More and more employer-sponsored (also known as self-funded plans) are also offering these medically necessary treatments through their employer sponsored health plans.
Recovery of Money for Services Owed
Even when you do everything by the book and have authorizations in writing, it is not always easy to get paid for services owed. Providers sometimes get in touch when they are owed in the hundred thousands. We are adept at reading through EOB statements, verifying non-payment, and getting plans to pay, with interest. For fully insured plans, we are happy to bring in the regulator, as well, and they are often happy to help. We are very efficient at recovering money, we charge on an hourly basis, not a percentage, which is usually much more reasonable than using a collections agency.
Effective Report & Assessment Writing That Results in Funding from Insurers
While many health insurers are required by law to provide ABA therapy, speech & OT, insurers are only required to provide these treatments when they are considered "medically necessary." Insurers may argue treatment is not medically necessary for a given patient. They may argue that the patient does not have severe enough symptoms to warrant treatment. Or they may argue that the patient is so severe that they are not likely to show improvement from the treatment. They may argue that the treatment should be obtained through the school district. Therapists need to be aware of these common arguments, and how to address them in writing up assessments, and progress reports. When care gets denied, sometimes it is a matter of rewriting the report to highlight what the health plan felt was lacking. We will work directly with providers and advise on how to write up reports to maximize the likelihood of getting covered.
Resolve Medical Necessity Related Disputes
As an autism service provider who accepts insurance, you should be seeking pre-approval from insurers before providing services for intensive behavioral treatments or ABA. We see cases where services are denied initially, and also upon renewal. When plans deny for medical necessity, they are required to tell you why. The most common reasons we see are slow progress, or has made sufficient progress and no longer needs treatment. Each argument needs to be appealed on its own individual merits. MHAIP assists families and providers through the appeal and regulatory review processes.
Employers & Employees in Self-Funded Plans
Self-funded plans are paid for by employers. As such, they are not held to the same stringent requirements as fully-funded, state-regulated plans. You cannot tell that a plan is self-insured by looking at the card. Providers need to verify to make sure that autism benefits are covered, and at what amount, before services begin. It is important to know what is and is not covered when working with self-insured plans. We can help and advise you on this.
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