Streamlining Utilization Review for Applied Behavior Analysis

By: Dana D’Ambrosio, MS, BCBA, LBA
Person looking at health insurance form on tablet with a laptop and coffee on the table

Applied Behavior Analysis as a covered benefit is a relatively new venture for Behavior Analysts. With 50% of currently practicing BCBAs having been certified in the last 5 years and insurance submission processes not included as part of their graduate curriculum, the variability in quality, style and data in treatment plans submitted for authorization leads to an arduous review process for health plans.

Combining the large discrepancies between provider treatment plans, the array of severity of symptoms and treatment methods, unclear documentation, and specific health plan requirements with complex medical necessity criteria, utilization managers are being set up with a subjective, inconsistent decision-making process.

Objectivity: How It’s Skewed

Managed Care Organizations and Health Plans have different staffing options in terms of who review ABA treatment plans for authorization of services for members with Autism. The gamut runs from nurses to social workers to BCBAs and yet, regardless of credentials, there is always a significant level of subjectivity across reviewers.

The problem lies in the experiences and perspectives of the reviewer, even when comparing treatment plans to the most stringent of medical necessity criteria.

As reviewers individually analyze each member and their treatment plan, while considering the extensive list of other factors: length in treatment, historical progress/regression, symptoms and severity, co-morbid diagnoses, barriers to treatment etc., they need to ensure high quality of care is being provided, and the benefit is being used appropriately. This process ultimately leads to great disparities in inter-rater reliability between reviewers.

Standardizing the Review Process

To increase objectivity and accuracy of decision making and reduce opportunities for outcomes that lead to avoidable harm or wasteful allocation of resources (BACB Guideline 3.01), it is imperative that health plans initiate a standardized review process for autism care management.

By consistently applying ABA benefits and quantifying response rates to treatment, payors ensure high quality of care is provided for services that are, in fact, medically necessary. With a decision-making algorithm, for instance, reviewers can dissect treatment plans, regardless of length/style, into a uniform layout of the most relevant information, while analyzing and monitoring members and their progress on an individual basis.

The key component of such a model is to guarantee each plan is still reviewed on its own, as each case has its own nuances which need to be accounted for, yet the structured elements which guide the decision are reviewed in a regulated way.

By having a standardized tool that ensures submission of a complete medical record, the information expected for treatment plan submission is clearly defined for providers (BCBAs) and the reviewer can then use this as a guide for pinpointing conversation topics, ultimately reducing the communication barrier between the health plan and provider. This shortens the review process and decreases latency to care.

RethinkFutures’ Solution to Optimize Medical Necessity Review

RethinkFutures’ Clinical Decision Support solution leverages millions of data points, modern data science, and clinical expertise to recommend an evidence-based treatment approach, including appropriate dosage of ABA therapy. Utilization reviewers systematically review providers’ treatment plans and use the tool’s recommendations to guide a personalized care decision.

For more information about Clinical Decision Support and the RethinkFutures’ platform, visit our Platform page.

How RethinkFutures Partners With Payors

RethinkFutures is part of RethinkFirst, a global health technology company providing cloud-based treatment tools, training, and clinical support for individuals with developmental disabilities and their caregivers.

RethinkFutures platform leverages millions of data points, modern data science, and clinical expertise to help payors optimize care at the individual level and across their ASD provider networks.

To learn more about the solutions, contact us.

About the Author

Headshot of Dana D’Ambrosio, MS, BCBA, LBA, Clinical Development for RethinkFutures

Clinical Development

Dana D’Ambrosio leads Clinical Development for RethinkFutures. She is a New York state licensed and Board-Certified Behavior Analyst. She brings over a decade of clinical knowledge, with experience spanning from direct patient care in various treatment settings to utilization and care management within the payor realm. She specializes in the creation and enhancement of technology solutions utilized by providers and health plans, to ensure best practice, high quality, coordinated care and streamlined review processes for all parties. She received a BS from the University of Central Florida and an MS degree in Counseling, specializing in Applied Behavior Analysis, from Nova Southeastern University.

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