Preventing Insurance Denials of Applied Behavior Analysis Treatment Based on Misuse of Medically Unlikely Edits...

The importance of obtaining full insurance coverage of all medically necessary applied behavior analysis (ABA) services without artificial limits on scope, intensity, duration, or beneficiaries of treatment is at the core of autism health care advocacy. Although some limitations, such as dollar limits, treatment hour caps, or restrictions on location of services or symptoms treated are obvious, others are more nuanced. One such area meriting increased attention is insurers' use of Medically Unlikely Edits (MUEs) in ways that can improperly limit care, reduce access, and undermine quality. Unfortunately, behavior analysts may unwittingly act as ambassadors for improper limits by treating MUEs as fixed limits on treatment and conscientiously counseling fellow practitioners to adhere to MUEs as if they cannot lawfully be exceeded. This is not surprising given that a number of payors appear to apply MUEs for ABA in exactly that erroneous fashion. In fact, MUEs arise from a program implemented by the Centers for Medicare and Medicaid Services (CMS) to flag potential fraud and billing errors and are not and never were intended to limit medically necessary ABA. As ABA practitioners seek to preserve and expand funding that allows treatment in accordance with generally accepted standards of care, care must be taken to ensure that practical administrative procedures and billing requirements do not undermine these efforts. Correct utilization of MUEs should be on the agenda of payors, regulators, policymakers, and behavior analysts to safeguard access to ABA, free of improper limits that threaten to lower the standard of care.