At this year’s CASP conference, an insightful discussion unfolded on the topic of value-based care (VBC) measurement, featuring industry leaders Yagnesh Vadgama, Doug Moes, Rebecca Womack, and Raven Health’s very own Tim Crilly. The conversation highlighted the challenges and opportunities in transitioning to VBC models within the autism services sector. The segment’s panelists drove home some key takeaways for the attendees.

Introduction and Perspectives

The discussion featured perspectives from various experts:

• • Tim Crilly: SVP of Partnerships at Raven Health, with a background in both clinical and managed care sides of ABA.
  • Rebecca Womack: Vice President of Quality Assurance at Verbal Beginnings, focused on policy and clinical solutions intersecting with payer requirements.
  • Doug Moes: Chief Clinical Development Officer at the Stepping Stones Group, providing a provider perspective on quality and outcome initiatives.
  • Yagnesh Vadgama: Vice President of Autism at Magellan, offered an overview of value-based care from a health plan perspective, advocating for a comprehensive approach that includes various aspects of autism care beyond ABA.

Defining Value-Based Care

Yagnesh Vadgama explained that value-based care is not a novel concept in healthcare, with approximately 60% of healthcare already operating under some form of value-based arrangement, primarily in physical health areas like cancer and diabetes. He emphasized the need to look at autism care holistically, integrating various treatments and services to enhance overall quality and outcomes. “We have to start somewhere,” he noted, advocating for initial models based on case rates with potential for bonuses tied to outcomes on measures like the Vineland.

The Shift from Fee-for-Service to Value-Based Models

The panelists discussed the limitations of the current fee-for-service model, which often leads to inefficiencies and a lack of focus on overall quality. Rebecca Womack pointed out that value-based care forces participants to prioritize time efficiently, focusing on outcomes that matter to families and payers. She stressed the importance of selecting quality metrics that provide a good return on investment for all stakeholders.

Doug Moes highlighted the importance of focusing on quality inputs, such as robust assessment and treatment planning, treatment integrity, and fidelity of implementation. He emphasized the need for partnerships and collaborative efforts to enhance the quality of life for individuals with autism.

Addressing Clinical and Administrative Changes

The transition to value-based care requires significant changes both administratively and clinically. Vadgama mentioned the success of value-based arrangements with providers like Kyo, which have led to greater staff retention and satisfaction. This model allows clinicians to focus more on care coordination and addressing the holistic needs of families rather than just meeting billing requirements.

Womack highlighted the importance of not making assumptions about the knowledge base of practitioners, stressing the need for thorough assessment and training to ensure successful implementation of value-based care.

Technology and Data Integration

The role of technology in supporting value-based care was a major point of discussion. Moes expressed excitement about the potential of technology to ease the burdens on clinicians and improve data collection and analysis. He envisioned a future where AI and machine learning could provide reliable data extraction from audio and video samples, unleashing passive data collection and allowing clinicians to focus more on treatment delivery.

Crilly pointed out the need for integrated systems that can pull together data from various sources to provide a comprehensive view of patient progress and outcomes. He mentioned the potential of remote patient monitoring codes and the benefits of incorporating wearable devices to track sleep and other health metrics.

Standardization and Collaboration

An audience member raised the question of standardizing data reporting between payers and providers. Yagnesh Vadgama acknowledged the importance of this and mentioned that it central to the industry’s roadmap for value-based care. The goal is to move towards more database-type submissions that allow for better tracking and analysis of provider performance and patient outcomes.

Rebecca Womack emphasized the need for the ABA profession to define its own standards and communicate them effectively to stakeholders. She highlighted the importance of balancing clinical decision-making with payer requirements to ensure the best outcomes for families.

Closing Thoughts

The session concluded with a call for collaboration and continuous improvement. The panelists acknowledged that while the transition to value-based care is challenging, it offers significant potential for improving the quality of autism services and achieving better outcomes for families.

Thank you to CASP for hosting such an insightful session!

Welcome back to our blog series tailored for BCBA entrepreneurs embarking on the journey of opening their own ABA therapy clinics. You’ve come a long way since hanging out your shingle: after coming up with your new clinic’s name, you already have started payor contracting, credentialing, and enrollment. Congratulations – you’re ready to start seeing clients! All you have to do is start administering services and billing your in-network payors.

Not so fast!

Today, we will explore the crucial process of obtaining prior authorization from payors before beginning treatment with new patients. This step is vital for ensuring that the services you provide are covered under the client’s health insurance plan, thereby securing your clinic’s revenue and facilitating effective care delivery

Understanding Prior Authorization

Prior authorization is a requirement that your client’s insurance provider must approve certain medical services before you perform them. For ABA therapy, this is particularly important due to the high costs associated with long-term treatment plans. Prior authorization helps ensure that the proposed services are covered under the client’s current health insurance policy and are medically necessary.

Step-by-Step Guide to the Prior Authorization Process

1. Verify Insurance Coverage: Before initiating any treatment, verify the client’s insurance coverage. Determine if the insurance plan covers ABA therapy and to what extent, including any caps on the number of sessions or total coverage amount.

1. Gather Required Documentation: Collect all necessary documentation to support the prior authorization request. This typically includes:
   • Client’s diagnostic information confirming an autism spectrum disorder diagnosis.
   • Proposed treatment plan outlining the goals and duration of therapy.
   • Clinical notes and assessments that justify the need for ABA therapy.

1. Submit the Authorization Request: Submit the prior authorization request form to the insurance company. Ensure that all fields are accurately completed to avoid delays. Some insurers require submission via specific platforms or portals, so it’s important to follow the payor’s prescribed submission process.

1. Follow Up Regularly: Insurance providers may take anywhere from a few days to several weeks to process a prior authorization request. Regular follow-ups can ensure your request is being processed and can help expedite approval. Be prepared to provide additional information if the insurance company requires further clarification.

1. Communicate with the Client’s Family: Keep the client’s family informed throughout the process. Clear communication about the status of the authorization and any potential delays is crucial for maintaining trust and managing expectations.

1. Receive and Review the Authorization: Once approved, you will receive an authorization notice detailing the approved number of sessions or coverage amount. Review this document carefully to ensure that it matches the requested treatment plan. If there are discrepancies, contact the insurer immediately to address them.

1. Document Everything: Keep detailed records of all communications with the insurance company, including dates of submissions, follow-ups, and copies of the authorization. This documentation will be invaluable in case of disputes or audits. 

Tips for Streamlining the Prior Authorization Process

• Educate Your Team: Ensure that all team members involved in the prior authorization process understand the steps and requirements. This includes training on how to complete forms accurately and manage follow-ups effectively.

• Utilize Technology: Consider using practice management software that includes features to help manage prior authorizations, track the status of pending requests, and store client insurance information securely.

• Build Relationships with Insurers: Establishing good relationships with insurance providers can facilitate smoother communications and quicker resolutions of issues that may arise during the prior authorization process.

Conclusion

Obtaining prior authorization is a critical step in the process of providing ABA therapy. While it can be complex and time-consuming, understanding and efficiently managing this process is essential for the financial stability of your clinic and the uninterrupted care of your clients. Stay proactive, organized, and patient—qualities that are as important in business as they are in therapy.