There are a few welcomed changes to the ABA program in these proposed regulations that will greatly enhance the overall quality of the program. This includes aligning the CPT codes with the industry, allowing for groups, and making clinic-based services more readily available than under the previous regulations. Despite these enhancements though, I have concerns with how these new regulations will be applied by the industry that will lead to some unintended consequences. Having been connected with CMHRS services over the last 17 years, what is pretty apparent is that providers and the industry, will move towards what makes for the easier business model, even if it does not always mean the best quality services. This is true, even when not intended. Applying that lens to these draft regulations causes me concern as it will greatly effect the quality of services that clients will receive from the program. The two main concerning areas are the lack of restrictions around the use of the clinic setting and the inability to bill for many non-face to face services. Here is why they specifically concern me:
- Lack of restrictions around the use of the clinic setting: Virginia Medicaid has always put a large value in home-based services both in ensuring clients have access to services and ensuring that they are more inclusive of the family and in the home setting. While home-based is certainly still allowed in these new regs, most providers will move away from doing much if any home-based services at all because every hour in the home will be more costly and will reduce the number of billable hours an LBA can do. With increased LBA rates, most providers will will make the decision to do what is by far more financially advantageous by having client’s brought into the clinic where an LBA can bill face to face services most of the day and maximize their billable income. This will greatly limit the LBA’s access to the home and will reduce home-based services as a whole. This would be a huge loss for the quality of care that would be provided.
Suggestion: Include specific rules around where services are delivered. If home-based services are deemed an important part of this program, they would need to be mandated through the regulations to ensure they continue and then verified through a location code attached to billing so it can be easily tracked. This mandate can either happen for example by saying home-based needs to be the majority of hours, or have providers request what percentage of hours will be delivered in the clinic setting at the time of authorization.
- Inability to bill for non-face to face services: In order for LBAs to provide quality ABA through delegation, they need to be able to develop and write individualized and specific treatment protocols. While I understand and appreciate the idea of these services being ‘in-kind’, there is too much of a disparity between the amount of time it takes to develop treatment in a quality way compared to simply having basic treatment that will satisfy the minimum requirements in the regulations. This disparity will lead to providers spending less time prescribing treatment in the most effective way as that would take away from there billable time and they will need to hit billable quotas from their providers. This will certainly lead to generic, lower quality treatment.
Suggestion: Allow and H code to bill for the development of behavior plans and protocols so LBAs are not disincentivized to write quality, individualized plans. Even if this code had a slightly lower rate than the other codes, it would still provide some incentive to do the amount of work required to provide the level of treatment that all client’s deserve.
Thank you for your consideration of this feedback.
