| Abstract: With nearly all US states now having insurance autism mandates, more and more providers are turning to health insurance as the primary funder of ABA services for Autism. This talk will lay out a template describing what providers need to know when facing insurance denials. We will use specific, real life cases and discuss how providers can address them. We start by looking at the specific written reason given for denial. Common reasons which we routinely encounter, many of which will be discussed include location (school vs home), disputes about hours of coverage, duration of the program, not benefitting from services, no longer needing services, parental involvement, as well as disputes about payment and coverage. When reviewing reports, health plans often look for descriptions of progress balanced with continued description of deficit and need. This can be highlighted in the appeal, depending on the stated reason for denial. Health plans typically cite their own guidelines in issuing denials, some of which are overly restrictive. A series of recent legal actions have brought some of this to attention -- shortcomings can be addressed and guidelines developed by professional bodies can be cited instead. When and what type of literature to cite and/or include will also be discussed. Even when done right, health plans typically uphold their own denials. Often the external review process is where real "justice" occurs. We will discuss what to include with external reviews, how the process works, and what types of plans are typically supported. Building relationships with state regulators and legislators is important. Finally, we will examine some of the laws which confer protection, including the Federal Mental Health Parity and Addiction Equity Act, and many sections in the Affordable Care Act. |