Best Practices for Implementing Rethink's Medical Necessity Assessment

Applied Behavior Analysis as a covered benefit is a relatively new venture for Behavior Analysts.

Combining the large discrepancies between provider treatment plans, the array of severity of symptoms and treatment methods, unclear documentation and specific health plan requirements with complex medical necessity criteria, utilization managers are being set up with a subjective, inconsistent decision-making process.

Open panel discussion: Why standardized review processes are needed, including a testimonial from a health plan representative.

The purpose of Applied Behavior Analysis for children with Autism is to increase quality of life by decreasing symptomology.

This goal is agreed upon by providers, families, and payors alike. The trouble achieving best outcomes stems from inconsistency in the monitoring of individualized progress over time. By comparing previous and current treatment records, all involved are better able to determine clinically significant progress and potential barriers to treatment, thereby ensuring quality of care is provided. Taking that data a step further, synthesizing and benchmarking it, allows for the potential to meet quality of care standards and can lead to value based care initiatives.

Open panel discussion: Strategic Operations Leader/ former Corporate Vice President of Clinical Services discuss the importance of using data to monitor progress over time and ensure quality of care standards

As the world continues to move away from in person appointments and toward technology, the ability to monitor and address Social Determinants of Health becomes increasingly difficult.

Caregiver outreach spans from ensuring health plan requirements, such as standardized testing, are met to providing education and resources. In order to maximize benefits of ABA therapy, there needs to be a holistic stance on supporting the family unit as a whole. Caregiver fatigue and behavioral health are often not considered when Care Managers are reviewing barriers to treatment and the best ways to allow the child and family to maintain and generalize the skills learned in ABA.

Panel discussion: How quality outcomes can be improved through member engagement when social determinants of health are considered.