Staying Ahead of the Curve on Changes Around Reimbursement for Autism Services

The autism therapy space has seen significant changes around reimbursement in recent years, and the providers in the space who aren’t keeping up are at risk of being left behind, says Jeff Skibitsky, MA, BCBA, LBA, president of Alternative Behavior Strategies.

Skibitsky founded ABS in 2011, and the company now operates facilities in California, Utah and North Carolina, with a team of more than 500 clinicians providing services for children with autism spectrum disorder. Speaking with BHE, Skibitsky says three main factors have driven changes around reimbursement for applied behavior analysis therapy services within the past five years.

First, the industry has evolved from mom-and-pop operators to sophisticated provider networks. The consolidation has given more providers a unified voice to advocate for more normative rates.

Second, as the industry shifted to a CMS-designed coding structure, providers have maintained carrier pricing. “What that means is we have been able to negotiate pricing with our payer networks due to the fact there are higher autism incident rates and longer wait lists because you’ve seen not only a higher incident [rate] within the population, but the people who have been deemed able to access care—it used to be the ages of 2 to 10—that has grown into an adulthood for most states right now,” Skibitsky says. “You’re bringing more of a need into the market without enough providers, so providers still have the ability to negotiate contracts that are favorable.”

Parity laws are a third factor helping providers by preventing the exclusion of the use of center-based care in what has historically been a home- and community-based space, Skibitsky says. Providing care in a center reduces a lot of extraneous costs—unfunded events such as travel time and increased cancelations—that have pushed some smaller providers out of the market, he adds.

Maximizing reimbursement

There are some steps for autism therapy provider organizations can take to strengthen their negotiating position, Skibitsky says.

• Develop outcome-oriented data. Increased investment into the field is a tailwind that brings resources for providers to develop more outcome-oriented data to use in negotiations with payers. This includes data on length of stay, utilization and patient progress.
• Increase the level of sophistication for business development practices, revenue cycle management, and authorization and benefit work. By creating efficiencies and a better understanding of their own data to determine costs of service, providers are better position to educate payers and negotiate reimbursement rates, Skibitsky says.

Avoiding pitfalls

In terms of missteps, Skibitsky says pushing outcome data aside for growth to occur has proven to be an unsustainable model.

“Providers who were trusting the fact they could grow without having appropriate quality controls and quality assurance, they’re going to end up suffering in the long run because of some of those strategies,” Skibitsky says. “Not utilizing data, not being able to aggregate, not using the technology that’s out there to become more efficient or produce higher quality results. The organizations that have put in the time and energy to take advantage of those components are the ones who will be able to continue to thrive as the field itself consolidates and becomes more competitive within the landscape.”

Another mistake has been accepting terms and rates not conducive to being able to invest in the quality of care. This includes letting payers take control of reimbursement discussions and not having the business development capable of pushing back to negotiate better terms. Also: Accepting all patients on all contracts without understanding the financial implications that decision could have on your business structure and your ability to be able to grow and invest in quality resources for your organization is a misstep to avoid, Skibitsky says.

Lastly, providers should also diversify their payer mix and understand the need for competitive analysis and differentiating factors. “A lot of times when there is so much need out there, that ability to differentiate and understand what makes a strong organization a strong clinical practice isn’t where time and energy is being resourced,” Skibitsky says.

Ultimately, Skibitsky says, providers should continue to study up on variabilities and changes within the market and not rely on payer-driven documentation.

“Education on the provider side needs to continue to be able to push back and make sure payers are providing the access to care that the members they represent deserve,” he says.