An area that we really encourage behavior analysts and others involved in the delivery of therapy for individuals with autism is to read some documents that may not be as entertaining and interesting as journal articles. Students in behavior analysis are often told to make sure that they are “evidence-based” and to stay on top of the current interventions by reviewing journals, such as the Journal of Applied Behavior Analysis. Readings that are often overlooked are insurance mandates, contracts with insurance companies, and medical necessity definitions.
Fast forward to today and it is absolutely imperative to make sure that a behavior analyst is reviewing these types of documents, and that they know what to look for. Tim Courtney, LittleStar COO, has started conducting trainings throughout the country with Dan Unumb of Autism Legal Resource Center, an attorney well-versed on the essential language and issues that readers should look to spot within these documents. A part of the training is to “issue spot” an insurance mandate.
The two speakers will usually select the insurance mandate based upon the current state in which they are presenting. Recently, they looked at the Colorado mandate and noticed something very interesting within the mandate language. The mandate indicated:
(g) A carrier may not deny or refuse to provide otherwise covered services, refuse to issue, renew, or reissue, or otherwise restrict or terminate coverage under a health benefit plan because the individual or his or her covered dependent is diagnosed with an autism spectrum disorder or due to the individual’s or dependent’s utilization of services for which benefits are mandated by this subsection
This language would allow providers to recommend the level of service that is medically necessary without concern due to the availability of the patient.
Often, they are asked during the workshop if the utilization of hours could be used against them for future authorizations. In the Colorado mandate, the language gives something that providers could reference upon encountering this type of challenge. The workshop also addresses other types of challenges.
If you have challenges related to this or are interested in finding out more about the workshop that Tim and Dan will be hosting next, visit Autism Legal Resource Center. The next workshop is a two-day workshop addressing several different areas related to navigating the ever-changing medical necessity landscape.