Healthcare is a complex industry with strict rules and regulations for professionals and patients. Regarding specific treatments like Applied Behavior Analysis (ABA) billing, remaining compliant is critical to ensure patients are treated on time. ABA therapy is one of the leading treatment plans for autism spectrum disorder (ASD).
Thus, understanding and adhering to the regulations is paramount. This article explores legal compliance and strategy.
Understanding ABA Billing
Before we explore the legal and strategic aspects of billing, you must understand what it entails. ABA services include several interventions aimed at improving the lives of individuals living with autism.
Each treatment plan addresses behavioral challenges and enhances social and functional skills. These treatments are done in several ways, including therapy, behavior management, assessments, and more.
Treatment for autism, as listed, has ABA billing codes that must be followed to ensure on-time treatment for patients and on-time payment for healthcare workers.
Typically, ABA services are reimbursed in several ways, including private medical insurance, government assistance programs, etc.
However, specific codes, document requirements, and compliance requirements must be met to ensure accurate and timely reimbursement.
Remaining Compliant With Healthcare Laws and Regulations
When remaining compliant, there is a lot to consider, but at the center of it is ensuring patients are afforded the best care timeously.
Additionally, healthcare workers should too be reimbursed for their work on time. For this reason, it is essential to familiarize yourself with some of the healthcare laws and regulations. Some of them include:
- Health Insurance Portability and Accountability Act (HIPAA) ensures that patient data is protected at the highest level.
- Affordable Care Act (ACA): This Affordable Care Act involves the coverage of health services and benefits.
- Medicaid and Medicare regulations: These standards are outlined by both organizations and must be adhered to.
- State licensing laws: Complying with state laws by ensuring your licenses and credentials are up to date and aligned.
Accurate Coding and Documentation
Accurate documentation is at the heart of billing best practices. Accurately recording patient and billing information leads to compliance and a smoother billing process.
Healthcare providers must obtain and maintain detailed records of each patient they serve; this includes all health information, assessments, medical history, medication currently in use, allergies, etc. Documents should be the following:
- Time-sensitive: Information should be recorded before, during, or after sessions to ensure no delays.
- Comprehensively structured: Include all relevant details such as patient name, treatment plan, and goals.
- Legible: Each document should be legible and comply with industry standards or those set by regulatory bodies.
Another aspect of documentation is billing codes. ABA services are billed using the Healthcare Common Procedure Coding System (HCPCS) Level II codes, including the following:
- H2019: Behavioral health counseling, per 15 minutes.
- 0364T: Adaptive behavioral therapy, first 30 minutes.
- H0031: Mental health assessment by a non-physician.
These are but a few appropriate billing codes; several others exist. It is important to note that codes are reviewed and updated occasionally. For this reason, it’s essential to stay up to date with updates as and when they arise.
Payer Compliance
Who are the people or organizations responsible for paying a medical bill? What does this entail, and what policies dictate how this process should be managed?
There are several elements to consider concerning who is paying the medical bill. Billing policies clearly define the guidelines, including those of private insurance companies, Medicaid, and more. Here are some points to consider:
- Pre-treatment authorization: Some organizations require pre-authorization before treatment can commence. Keep a list on hand to help speed up the authorization process.
- Check patient coverage: Each medical plan has different elements for which they pay. Ensure you understand the criteria for ABA therapy, including diagnosis, session limits, etc.
- Reimbursement rates: You must comply with Each organization’s contract and fee schedule. Ensure you are up to date on their reimbursement rate so that there are no delays in payment.
Preventative Measures
Some aspects to consider are fraudulent activities and abuse. While the medical industry is highly regulated — and for good reason — remaining vigilant is paramount to prevent fraud and abuse in billing practices. Here are some points to consider:
- Avoid upcoding: This process involves billing for services that are more complex than what you treat someone for.
- Prevent double billing: You must check that services are not billed twice under separate codes.
- Remain compliant with the Anti-Kickback Statute and Stark Law: This prevents medical providers from paying or receiving kickbacks in exchange for patients receiving treatment paid for by government organizations.
- Implement internal controls: Establish internal controls and checks that monitor billing activities and that can check for any irregularities.
Compliance Is Important and Needed
Healthcare providers have one goal: to serve their patients to the best of their abilities. This process involves billing, complying with regulations, and using the correct billing codes.
This process becomes even more complex when relating to ABA therapy. Medical providers are encouraged to understand ABA billing codes, stay compliant with regulatory bodies, have accurate patient documentation with the correct billing codes, understand the role of the payer, and have fraud-preventative measures in place.
