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Eligibility and Benefit Verification - Why is it important for ABA therapy?

This can be a major reason that a practice can have a loss worth thousands of dollars in revenue if wrongly eligibility information is accounted for.

Figuring out the patient benefits is time-consuming and a challenging process, but it leads to making sure that providers get paid on time. However, many ABA therapies still have limitations and exclusions in many states. Employers who provide self-funded benefits can choose to exclude or limit services, even if the state mandates that autism-related services be covered.

For Instance, assume ABA therapy insurance coverage may be limited to a max of $45,000 in reimbursement for that year, but you may receive an authorization that exceeds this cap. Hence it is important to know exactly what & how services are covered to alert and prepare the provider and the patient from unexpected denials and bills.

Eligibility can be tricky and change in various ways throughout the year:

  • It is important for a biller to know the patient’s deductible, out of pocket costs, and the calendar period of the plan before authorizing any therapy.

  • Any biller should communicate with patients about any job changes, and how it will in turn affect their insurance coverage. Also do they have buffer time? Are they going to utilize other coverage? Will there be a new insurance policy?

  • As it's a common practice for providers to opt for Medicaid throughout the different times for eligibility of patients. It's important that the patient is aware of new Terms and Condition of that policy

The financial obligations of insurance for ABA therapy can be difficult to understand at times hence avoid letting patients’ out-of-pocket costs get in the way of providing service If a patient does not understand their obligations, those become unaccounted dues. ABA therapy in particular can be very costly, hence without any advance notice, most patients cannot afford or plan for payments of that magnitude. Therefore setting up a payment plan in the initial stages of services helps reduce stress for everyone involved in the process.

At Amromed LLC, we pride that our team of experts do a comprehensive study and understand the ABA insurance eligibility verification process prior to the initiation of services. We also do through ongoing verifications. We take extra steps to explain benefit details to providers, so they can offer services within the scope of the benefit limitations.

Reach out to learn more about this and other financial obligations we can help you with, such as deductibles, copays, and out-of-pocket maximums.

Contact us at 909-907-0789 or

Don’t skip this critical step in generating a higher Revenue Cycle!


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