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Rethinking the ABA Revenue Cycle

By Claudia Wong and Sanjay Narasiwodeyar

A pervasive sense of fatalism dominates modern healthcare operations, where provider-payer friction is often accepted as an unpreventable tax on care delivery rather than a systemic challenge to be solved. Against that broader backdrop, this report focuses on operational friction in ABA providers’ interactions with private carriers.

Across healthcare ecosystems, provider-payer operational friction in navigating payer claim processes can significantly impact provider experience, practice efficiency, administrative & operational sustainability, and most crucially, financial outcomes for both practices and providers [1], [2], [3]. This problem does not necessarily present itself uniformly across all provider types, regions, or payer relationships [4]. A critical review of the landscape reveals a possible a set of latent factors that contribute to the observed complexity and variability in payer rules & requirements as well as provider experience during claim operations [5], [6], [7], [8], [9].

While it is tempting to conclude that there's an inexhaustible list of causal factors that vary across provider types and delivery contexts, we present here a novel framework that shows how these factors can be systematically categorized and understood along the dimensions of procedural and outcome specificity. This framework allows us to answer three key questions:

  • Where is the pain? That is, do some practice types tend to experience greater provider-payer friction than others?
  • What are the underlying causes of this friction?
  • Most importantly, are these issues preventable via improved provider side operational and technological innovations, or are they completely unpreventable outside of payer-side reforms via public policy?

Among the more complex care delivery contexts, Applied Behavior Analysis (ABA) practices face a unique provider-payer gridlock [5], [6], [7], [8], [9], [10], [11] that many consider unpreventable in the current healthcare landscape. However, empirical evidence to support such a conclusion is limited [10], [11], and current opinion on the matter is largely driven by anecdotal and fragmented observations [6], [7], [8].

Key Concepts:

  • Specificity: The degree to which procedural steps and desired outcomes are clearly defined and standardized for a given set of presenting problems.
  • Procedural: Related to the specific steps and actions required to execute healthcare interventions.
  • Outcome: Related to the desired results or endpoints of healthcare interventions, including patient health outcomes and treatment effectiveness.
  • Underspecification: The lack of clear, standardized guidelines for procedural steps or desired outcomes, leading to uncertainty and variability in both provider and payer actions [12], [13].

Causal Factors

As a point of reference, let us consider causal factors that drive complexity during a general medical visit. Presenting problems during a physician visit, for example, are typically specific or clustered in scope (e.g., localized pain, infection, or viral illness with multiple predictable symptoms) [14]. A pre-determined set of diagnostic and treatment protocols usually exists [14], which allow focused treatment of the underlying generative cause of the patient's multidimensional symptoms.

In contrast, ABA therapy often deals with complex behavioral presentations that are highly individualized [12]. Each patient may exhibit a unique combination of behaviors, triggers, and responses, which may not have an obvious targetable underlying cause -- i.e., current research into ASD (Autism Spectrum Disorders) can identify no singular pathophysiological, neurological, genetic, or environmental determinant that universally explains the observed behavioral patterns [15].

Specification Drives the Payer-Provider Operational Relationship

In healthcare operations, the degree of specification in procedural pathways and desired outcomes plays a crucial role in shaping the interactions between providers and payers. High specification reduces ambiguity, facilitates efficient resource allocation, and enables more predictable financial risk management. Conversely, underspecification introduces uncertainty, increases administrative burden [1], [2], [3], and heightens operational friction for both parties. To further clarify, underspecification means the lack of statistically dominant procedural pathways and outcome measurements, not necessarily that an individual treatment plan is inherently unclear or invalid [12], [13], [16].

In this framework, we define two types of underspecification. First, procedural underspecification is defined as the lack of clear, standardized guidelines for executing specific healthcare interventions, and second, outcome underspecification as the ambiguity in defining and measuring desired patient outcomes.

Procedural underspecification:

Consider a general medical procedure, such as an urgent care visit for a laceration. The steps involved, such as triage, wound cleaning, suturing, and follow-up, are well-defined and standardized across most healthcare settings. This procedural clarity allows both providers and payers to anticipate the necessary actions, allocate resources efficiently, and from the payers' perspective: accurately predict and manage financial risk.

Contrastingly, consider an ABA intervention session. The procedural steps are often highly individualized to the specific needs and behavioral goals of the patient [12]. A single intervention plan may be one among many combinations of protocols, techniques, and session structures, which in appropriate conditions may all be considered valid approaches [16]. This procedural variability may introduce uncertainty for both providers and payers, making resource allocation, financial risk prediction, and compliance monitoring more challenging and less predictable than in general medical practice [5], [12], [16].

Outcome underspecification:

In general medical practice, desired patient outcomes are often well-defined and measurable, such as achieving target blood pressure levels [14] or successful post-surgical recovery. Clear outcome specifications may enable providers to design appropriate care plans and allow payers to assess the effectiveness of interventions and manage financial risk accordingly.

In contrast, ABA interventions focus on individualized behavioral goals that may vary widely between patients. The desired outcomes are often context-dependent and may not have universally accepted metrics for assessment [12], [13]. This outcome ambiguity may introduce uncertainty for both providers and payers, complicating the evaluation of treatment effectiveness, financial risk management, and compliance monitoring [12], [13].

Operational Consequences of Underspecification

Underspecification in both procedural and outcome aspects of ABA interventions may lead to several operational consequences for healthcare providers and payers. These consequences may manifest as increased administrative burden, higher likelihood of disputes, and greater difficulty in predicting and managing financial risk [1], [2], [3], [11].

Increased Administrative Burden

Providers and payers may need to invest additional time and resources to clarify procedural steps and desired outcomes, leading to more extensive documentation, frequent communications, and repeated reviews [1], [2], [3].

Higher Likelihood of Disputes

Ambiguities in procedures and outcomes may increase the chances of disagreements between providers and payers regarding the appropriateness of care, coverage decisions, and reimbursement amounts [11].

Greater Difficulty in Predicting and Managing Financial Risk

The uncertainty introduced by underspecification complicates the ability of payers to forecast costs accurately and manage financial risk, while providers face challenges in ensuring timely and adequate reimbursement [3], [11].

Preventability Analysis

If underspecification in ABA is structural, does that automatically imply that the resulting operational friction is unpreventable, or are there aspects that can still be mitigated through improved practices and technologies?

Preventable vs Unpreventable Friction

  • Preventable Friction: Operational friction that arises due to factors that can be mitigated or eliminated through better communication and coordination practices and dedicated technologies within the practice.

  • Unpreventable Friction: Operational friction that arises due to factors that are inherent to the nature of payer rules and the underspecification of ABA procedural and outcome requirements, which cannot be easily mitigated through internal practice improvements.

Potentially Unpreventable Friction and Their Sources

  • Payer Policy Changes

    • Friction: Frequent changes in payer policies and requirements can create uncertainty and necessitate constant adjustments by providers [5], [8], [9].
    • Challenge: Since these changes are driven by external entities, providers have limited ability to anticipate or control them, making it difficult to fully mitigate the resulting friction [5], [8], [9].

  • Variability in Payer Interpretation

    • Friction: Different payers may interpret ABA treatment guidelines differently, leading to inconsistent authorization and reimbursement decisions [5], [6], [7], [11].
    • Challenge: Providers have limited influence over how payers interpret guidelines, resulting in ongoing uncertainty and the need for frequent clarification and negotiation [5], [6], [7], [11].

  • Delays in Payer Response

    • Friction: Delays in payer response to authorization requests or inquiries can disrupt treatment schedules and create administrative burdens [3], [4].
    • Challenge: Since response times are largely controlled by payers, providers may have limited ability to expedite the process, which may lead to delays and the need for contingency planning [3], [4].

What is Truly Preventable in ABA?

The most empirically grounded answer to this question today would be a resounding "we're not sure" [5], [6], [7], [8], [10], [11]. Preventable friction represents the operational inefficiencies and administrative hurdles that can be addressed through targeted interventions, improved workflows, and the adoption of adaptive technologies. Identifying and mitigating these sources of friction is essential for enhancing the overall efficiency and effectiveness of ABA practices. However, the challenge with enumerating preventable friction is that it requires empirical analysis of real-world practice operations that have not yet been systematically studied or documented [10], [11].

Over the years, certain administrative processes and operational inefficiencies in ABA practices have been identified and addressed through the implementation of standardized protocols, improved communication channels, and the integration of specialized practice management software [5], [7], [12], [17]. What's unclear is the extent to which these interventions have successfully mitigated preventable friction across diverse practice settings and operational contexts, and whether additional, yet-to-be-developed solutions could further reduce preventable friction [5], [7], [12], [17].

Core Opportunities & Challenges

It is not clear what portion of payer related operational issues in ABA can be correctly classified as belonging to the category of unpreventable friction. Though the existence of high under-specification in ABA [12], [13] could naturally lead to the conclusion that a significant portion of friction may indeed be unpreventable, there are confounding factors such as lack of empirical studies with direct practice-level data [10], [11], relative underinvestment from the technology sector on ABA-specific solutions, and absence of bespoke technologies that adaptively transform to the unique operational needs and rhythms of specific ABA practices and methodologies [17]. Collectively, these factors obscure the true nature of friction and hence may artificially inflate the appearance of unpreventable friction, as well as contributing to fatalistic attitudes among both providers as well as innovators [5], [6], [7], [8], [17].

  • A true north star for improving payer-related operational efficiency and sustainability in ABA practice is to systematically isolate and target the boundaries of preventable friction.
  • We believe that the path forward must begin by identifying the root causes of friction via stakeholder engagement and analysis, with two primary objectives:
    • Ensuring that technologists can develop ABA-native, bespoke solutions that effectively mitigate preventable friction.
    • Providing clarity and evidentiary support to providers, practices, and patients to understand which aspects of their experience arise from unpreventable causal factors, so they can effectively engage in and advocate for long term structural policy reform.

References

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