Before we get too deep into this blog post, I want to make it clear that I am by no means an insurance expert. I only work with a small handful of insurance companies and you will find that what I’m talking about can really differ, depending on what insurance company you work with and where you live. This is more of an overview of what it means to “submit” to insurance and the 4 different things I see happen when I submit on behalf of clients.
First, let’s talk about what a treatment plan is. Think of the treatment plan the same way you look at an IEP. The treatment plan covers assessments, progress on previous goals, new goals, proposed goals, transition plan out of ABA services when it’s time, service time I am requesting, and more. Most of the families I work with are seeking ABA therapy to be covered by their individualized insurance plan. As the BCBA, I write that treatment plan and submit it to their insurance.
From there the insurance company will review the plan and determine if they will pay for services. There will be a case manager on the insurance side that I coordinate with to get the plan approved. I usually see one of 4 scenarios happen when I submit a treatment plan.
Scenario 1: Approval
This is the best-case scenario. The insurance company will say your plan looks great. They give me the green light to move forward. They will give me a date to resubmit (usually 6 or 12 months later) but they don’t need anything else from me.
Scenario 2: Clarify, then approve.
Sometimes the case manager has a simple question that I can either call in to answer or send in an email. She can adjust the plan and then approve it. I see this happen when maybe I had a typo, or she wanted to clarify something small like the criteria for mastery of a goal. These are very quick fixes.
Scenario 3: Withdraw, fix, and re-submit to approve
Sometimes the case manager will have a whole list of questions. She might say why don’t you withdraw your plan, fix these areas and resubmit. Usually, this is not simple errors. It would be more something like they want to see more social skills goals to address those deficits, or they want me to re-approach how I am going to coordinate with the parents. It is still a quick fix, but it is more than what can be clarified on the phone so they have me re-submit once the plan is updated.
Scenario 4: Peer Review
This is the worst-case scenario. This is when there are numerous concerns about a plan and it’s more than just me fixing one or two things on my end. In my experience, I usually see a peer review happen when I’m asking for an increase in services if the child does not appear to be making adequate progress if there are major behavioral concerns or something like that.
I will have to go to a formal meeting, sometimes with a BCBA-D that is contracted by the insurance company to basically pitch my plan, explain why services are necessary, and work with them to get the client approved. These are really stressful scenarios because I’m in meetings with people that don’t know my client.
They have no picture of who the child really is beyond what I have written in the document. I’m having to convince this person that my client really does need therapy and I need to have all of the data and information ready to back me up. These are though but sometimes a necessary part of being a BCBA.
If you are a brand new BCBA and don’t know what to expect with insurance, I hope this helps you feel more prepared for what might happen. Want to know more about the peer review process? I have 5 tips in another blog post, click the image below to go to that post!
