Translating Medical Necessity Criteria (MNC) for ABA Providers Working with Health Plans

RethinkCare logo
RethinkEd logo
RethinkBH For Providers logo
RethinkBH For Health Plans logo

By: Rethink

folders tightly lined up in a shelf

Share with your community

Facebook
Twitter
LinkedIn

The live webinar for part 3 of our Medical Necessity Criteria Series will take place on Thursday, June 20th, 2019 at 1:00 PM ET.

We will also unveil our brand new, industry-first Medical Necessity Criteria Assessment Tool for ABA Services!

Be one of the first to see it in action by attending the webinar.

Register now!


This piece was based upon a recent webinar presented by Tim Crilly, BCBA.

Tim spent 3 years as Director of Autism Services for a major national health plan and an additional 10 years for a provider group in California.

Conceived over 50 years ago out of the idea that positive gains can be made in an individual’s behavior by applying principles of learning and techniques, the scientific practice of Applied Behavior Analysis (ABA) is a relatively new concept in the healthcare industry.

Although the process has many different elements, health insurance managers and teams often receive only a snapshot of the type of care being offered to individuals in need of treatment.

Health insurance organizations use this snapshot and medical necessity criteria (MNC) to define the benefits they cover for their members.

However, not all snapshots or MNC are created equal.

Medical necessity criteria can vary from organization to organization.

The guidelines help to determine levels and types of care that are considered medically necessary for an individual’s behavioral health.

Many health insurance companies also opt to create their own MNC or LOC guidelines, although there are commonalities.

How Managed Care Teams Use Medical Necessity Criteria

Below are three common phases of interpretation for MNCs:

  • Initialization of care: Set of criteria that determines if care is needed and at what level treatment should be authorized
  • Maintenance of ongoing care: Set of criteria that determines if care should continue at the current level
  • Change or termination of care: Set of criteria that determine if care should change

While the criteria most organizations use was originally meant to simplify the interpretation process, ABA is still widely misunderstood.

The challenge that insurance management teams face when reviewing care is that MNC and LOC guidelines don’t offer interpretations for appropriate levels of care.

Additionally, the lack of consistency in care within the ABA community only makes this challenge greater for insurance management teams, as they review a wide range of care requests that carry different recommended programming levels.

Challenges for Applied Behavior Analysis Providers

ABA providers also face challenges in providing care.

They include:

  • Struggling to align programming approaches and goals with requirements for MNCs
  • Requesting hours for ongoing services that are not in line with MNC/LOC guidelines
  • Pairing reduction behaviors with replacement behaviors
  • Creating caregiver involvement and goals and following through

To help solve the challenges for both insurance management teams and providers, it is important to start with one common element: The MNC.

To get through the metaphorical “front door” or past the initiation of care phase, providers should look at medical necessity criteria for every funding source they have to gain a better understanding of what’s expected at the initial intake phase.

Proceeding with the right level of care in the beginning of the process can also result in a decrease in denials later down the line.

If the original treatment is determined to be an appropriate type of ongoing care for an individual, it should then be clearly justified.

As health care definitions continue to expand, clear and concise justifications for ABA care are more necessary now than ever before.

Insurance care teams often look for the most cost-effective solutions for their business and their members.

Once ABA services become an ongoing offering, health insurance organizations calculate them as new lines of costs that they will attempt to reduce if possible.

How Care Management Teams and Providers Measure Success

To ensure clinically appropriate levels of care, providers must do a better job in gathering information and providing evidence for types and levels of care.

Doing so will help redefine the limitations for care and reduce instances when ongoing care is inappropriately changed or terminated at the expense of those who need it most.

Being smart about goal alignment also makes a difference when insurance management teams review reports.

Providers should ask themselves if they are sending in goals representative of what is outlined in an MNC while considering whether their goals are appropriate for funding through an insurance process.

Any behavior plans should be closely aligned with what is determined in an MNC.

Caregiver programming is perhaps one area with the most inconsistency when it comes to who is being placed in an environment and how much caregiver support is being provided.

This is a big factor for health plans, as an insurance management team evaluates care and wants to see it in programming.

Although goals should align with the MNC as much as possible, providers should also at times focus on additional services that are not outlined in the MNC if doing so will meet the overall needs of their clients.

With the vast majority of providers using digital data systems today, technology should help to make challenges easier to overcome.

Every ABA provider should analyze whether their technology platforms work hand in hand with health plans to ensure they are taking clinically, socially significant and ethical actions in programming and care that align with health plan values.

The technology platforms a provider uses should also offer the right tools and benefits for providers to share with individuals and families as care continues.

Ultimately, the success of health care plans should be measured by titration of care over time; transitions to less intensive care when appropriate; caregiver empowerment and consumer protections for member groups.

However, the measures of provider success are still being defined.

Future Plans

Over the next few years, it will be imperative for providers in the healthcare industry to come together cohesively to avoid regulations imposed by insurance management teams that miss the mark.

Providers should be upfront and coherent in their communication with each other, so everyone can appear on the same page to insurance management teams.

Clinically integrated networks, which can negotiate collectively with health insurance organizations, may be an opportunity for providers work together to protect the quality and consistency of care in the future.

Rethink Behavioral Health provides an intuitive and comprehensive solution to scale your ABA business and ensure client success.

Our one-stop-shop platform offers both Clinical and Practice Management tools along with RBT Training, VB-MAPP licenses, and over 1500 resources/materials as curriculum pieces.

Schedule a demo today at your convenience!

Share with your community

Facebook
Twitter
LinkedIn
Sign up for our Newsletter

Subscribe to our monthly newsletter on the latest industry updates, Rethink happenings, and resources galore. Simply follow the link to the footer and enter your email.

Related Resources

NEW YORK, Nov. 21, 2022 /PRNewswire/ — RethinkFirst, the leading software and solutions provider in behavioral health, today...
Webinar
Register for Webinar About this Webinar December 15th, 2022 @ 1 pm EST  In this...
Webinar
Enroll in Course Eligible for 1 free General CE  About this Free CE Webinar Dr....

Learn more about Rethink

African American male and Caucasian woman working on laptop drinking coffee
RethinkCare logo

Take care of your people with RethinkCare’s evidenced-based solutions that support the well-being your entire employee base in all aspect of their lives - from personal to parenting, and professional

For Employers ›
School learning with diverse middle school students
RethinkEd logo

Build strong school communities and healthy, safe learning environments for all your students with RethinkEd’s evidence-based strategies and technology solutions across SEL, Special Ed, Behavioral & Training

For Educators >
Doctor helping girl with psycho pedagogical intervention
RethinkBH For Providers logo

Start, grow and manage your practice with Rethink’s workflow automation and evidenced-based clinical best practice tools that help you optimize outcomes and operations

For Providers >
African American women talking while seated
RethinkBH For Health Plans logo

Support your members and your provider networks with Rethink’s solutions that support autism care management across your network while offering unique value-added services to your members.

For Health Plans >
logo rethinkfirst white

Together We’re Powering Potential

Transforming the Behavioral Health landscape requires scalable platforms that address a broad range of mental, emotional, and wellness needs. At Rethink First we are proud to work across the continuum of care to help individuals and the people they care about live healthier, happier and more fulfilling lives.

New call-to-action

The leading behavioral and mental health enterprise platform to support working parents, caregivers and their families.

For Employers ›
New call-to-action

Award-winning solutions empower districts and their educators to improve outcomes and wellness for all tiers of students and to build healthy and safe learning environments.

For Educators >
New call-to-action

Fully integrated workflow automation and evidenced-based clinical tools help behavioral health organizations optimize outcomes and operations.

For Providers >
New call-to-action

Patent-pending clinical solutions and member engagement services streamline autism care management processes and support outcomes for health plans, providers, and members.

For Health Plans >