Abstract
The importance of obtaining full insurance coverage of all medically necessary applied behavior analysis (ABA) services without artificial limits on scope, intensity, duration, or beneficiaries of treatment is at the core of autism health care advocacy. Although some limitations, such as dollar limits, treatment hour caps, or restrictions on location of services or symptoms treated are obvious, others are more nuanced. One such area meriting increased attention is insurers’ use of Medically Unlikely Edits (MUEs) in ways that can improperly limit care, reduce access, and undermine quality. Unfortunately, behavior analysts may unwittingly act as ambassadors for improper limits by treating MUEs as fixed limits on treatment and conscientiously counseling fellow practitioners to adhere to MUEs as if they cannot lawfully be exceeded. This is not surprising given that a number of payors appear to apply MUEs for ABA in exactly that erroneous fashion. In fact, MUEs arise from a program implemented by the Centers for Medicare and Medicaid Services (CMS) to flag potential fraud and billing errors and are not and never were intended to limit medically necessary ABA. As ABA practitioners seek to preserve and expand funding that allows treatment in accordance with generally accepted standards of care, care must be taken to ensure that practical administrative procedures and billing requirements do not undermine these efforts. Correct utilization of MUEs should be on the agenda of payors, regulators, policymakers, and behavior analysts to safeguard access to ABA, free of improper limits that threaten to lower the standard of care.
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Notes
The topic of medical necessity is nuanced and complex involving a variety of clinical and legal considerations and is beyond the scope of this article. Resources for those interested in learning more about this area include: Giardino and colleagues (2022), American Medical Association (n.d.), the Council for Autism Service Providers (2020), the Autism Legal Resource Center, and presentations and professional conferences (e.g., the Association for Professional Behavior Analysts, the Autism Law Summit, the CASP Conference).
The American Medical Association’s time-based CPT codes for ABA use 15-min units.
Some payor policies do indicate that the provider has a right to appeal a claims denial based on MUE, but even then, anecdotal information suggests that providers may not be being properly paid on appeal. An informal analysis of one national provider’s data involving hundreds of appeals across multiple national payors showed that no claims were paid on appeal, even though the provider had submitted uncontested data showing the services were (1) actually provided; (2) properly coded; and (3) medically necessary. This suggests that rigorous and comprehensive data collection and analysis of outcome data on appeals would benefit further advocacy in this area.
See, for example, Texas Department of Insurance FAQ guidance to insurers, which states, “if you give a preauthorization, you cannot deny or reduce payment for the reasons of medical necessity or appropriateness, which would be a determination made by the utilization review staff during their clinical review” (Texas Department of Insurance, n.d.). See, also, American Medical Association (2021) Prior Authorization State Law Chart.
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Kornack, J., Unumb, D.R. & Williams, A.L. Preventing Insurance Denials of Applied Behavior Analysis Treatment Based on Misuse of Medically Unlikely Edits (MUEs). Behav Analysis Practice (2023). https://doi.org/10.1007/s40617-023-00877-y
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DOI: https://doi.org/10.1007/s40617-023-00877-y