Association for Behavior Analysis International

The Association for Behavior Analysis International® (ABAI) is a nonprofit membership organization with the mission to contribute to the well-being of society by developing, enhancing, and supporting the growth and vitality of the science of behavior analysis through research, education, and practice.


46th Annual Convention; Washington DC; 2020

Event Details

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Panel #355
CE Offered: BACB
Working With Insurance Companies: Navigating Medical Necessity Criteria and Peer Reviews
Sunday, May 24, 2020
5:00 PM–5:50 PM
Walter E. Washington Convention Center, Level 2, Room 207B
Area: AUT; Domain: Service Delivery
CE Instructor: Karen Nohelty, M.Ed.
Chair: Karen Nohelty (Center for Autism and Related Disorders)
JULIE KORNACK (Center for Autism and Related Disorders)
KATHERINE A. JOHNSON (Learn / Advances Learning Center)

As insurers and health plans become the predominant funders of ABA-based autism treatment, behavior analysts increasingly encounter complex guidelines and unanticipated peer reviews as they endeavor to provide services to their patients. Each insurer/health plan has its own medical necessity criteria (MNC) to try to define which services will be covered. A comprehensive understanding of the proper use of MNC and how to prepare for a peer review has the potential to help behavior analysts successfully challenge erroneous treatment denials and arbitrary treatment limits. Numerous laws, regulations, and legal precedents protect a patient’s right to access medically necessary treatment, including ABA. For example, the Mental Health Parity and Addiction Equity Act (MHPAEA) prevents insurers/health plans from imposing stricter limitations on mental health benefits, such as autism treatment coverage, than those imposed on medical/surgical benefits. Results from a recent review of the MNC of 10 insurers/health plans will be discussed in light of MHPAEA requirements. Practical methods of conveying these requirements in interactions with insurance representatives will be discussed. Strategies for successfully navigating the peer review process will be shared. With an enhanced understanding of patient rights and provider responsibilities, clinicians will have the tools they need to provide ABA-based treatment that reflects best practices.

Instruction Level: Intermediate
Target Audience:

BCBAs who work with insurers as payors of ABA-based autism treatment.

Learning Objectives: 1. Participants will identify at least 2 strategies to aid in communicating a patient’s clinical needs to insurance carriers during a peer-to-peer review. 2. Participants will understand how MHPAEA protects patient access to ABA-based autism treatment and will be able to identify at least 2 elements in insurer guidelines that may violate MHPAEA. 3. Participants will be able to discuss the components of medical necessity criteria guidelines in the context of ABA-based autism treatment.
Keyword(s): insurance, medical necessity, MHPAEA, peer reviews



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Modifed by Eddie Soh