The American Medical Association CPT Editorial Panel released eight standardized and permanent codes for billing applied behavioral analytics (ABA) therapy services that became effective January 1, 2019. For the first time, adaptive behavior services are standardized for the purposes of billing and payment for those services by CMS and other third-party payors.

This should be good news for anyone involved in providing and receiving ABA services. However, as often happens with change, there have been issues with implementation. Some providers are concerned because they are submitting clean claims under the new codes, but they are not being properly paid by their patients’ insurers and other third-party payors. Some providers are being short-paid, late paid, or not paid at all for their ABA services.

There are at least three reasons the claims may not be going through payors’ systems correctly. First, some payors have not loaded the new CPT codes into their claims adjudication systems and tested those systems to ensure timely claims adjudication. Second, some payors contract with third-party administrators and clearinghouses for the purpose of claims adjudication. The clearinghouses and third-party administrators may be slow to modify their claims adjudication systems to accommodate the new service codes. Third, there are no standardized rates. Although some payors have contracted with third-party intermediaries to negotiate rates, this is as yet an ongoing and incomplete process.

What can be done?

If you are a payor: First, assign someone on your staff to keep up with changes in CPT codes so you can update your systems as soon as possible to avoid any issues of late paying your providers on clean claims submitted. Doing this will make your claims processing more efficient and help you maintain a healthy relationship with your provider partners. Second, be cognizant of the fact that the longer your system lags in processing claims for behavioral health codes specifically, the more you open yourself up to claims that you are violating the Parity Act. Third, many states have timely claims processing laws, and it is good practice to pay providers timely to avoid paying interest on clean claims.

If you are a provider: First, take advantage of the timely claims processing laws enacted in most states. The interest clock on late payments of claims triggers a statutory interest rate typically thirty (30) days after a clean claim is submitted for payment. Second, file an appeal. Third, going forward, negotiate with the payors you work with for specific rates. Taking these steps can help you be paid faster and give your payor partners a nudge to update their systems quickly (if they have not done so yet).

About the Authors:

Russell A. Kolsrud, Member, is a health care attorney in the Phoenix office and can be reached at 602-285-5054, rkolsrud@dickinson-wright.com and his biography is available here.

Erica A. Erman, Associate, is a health care attorney in the Phoenix office and can be reached at 602-889-5342, eerman@dickinson-wright.com and her biography is available here.