Abstract
As autism rates increase, providers of applied behavioral analysis (ABA) services are more frequently engaging with managed care companies to discuss the medical necessity of treatment. In an effort to maximize the efficiency and effectiveness of these reviews, we draw upon our experience as peer reviewers for a managed care company to guide ABA providers in discussions with managed care on behalf of their patients. In this article, we first provide an overview of the managed care peer review process. We then discuss the elements of medical necessity that managed care companies ask about during the review process. Finally, we review specific strategies that ABA providers can use during the process to optimize authorizations for payment for services. Throughout the paper, we provide sample dialogues between providers and peer reviewers based on our experience working for a managed care company along with specific recommendations that we hope will ensure a more collegial and effective peer review process for all involved.
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The authors thank Mr. Jeffrey Linstone and Dr. Douglas Nemecek and Dr. Vikram Shah for their helpful comments on the earlier drafts of this manuscript.
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The authors are employees of Cigna and have no conflicts of interest to declare.
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Papatola, K.J., Lustig, S.L. Navigating a Managed Care Peer Review: Guidance for Clinicians Using Applied Behavior Analysis in the Treatment of Children on the Autism Spectrum. Behav Analysis Practice 9, 135–145 (2016). https://doi.org/10.1007/s40617-016-0120-5
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DOI: https://doi.org/10.1007/s40617-016-0120-5