Variables to Contemplate in Negotiating Rates*

*Please note that discussion of rates with other providers may violate federal and state laws. The following information is solely intended to inform an individual provider’s understanding of the variables to contemplate when negotiating or accepting rates. Providers are urged to consult an attorney and other professionals to ensure they are well represented in any negotiation process.

When determining whether to accept a payor rate, consider the following:

  • What does it cost to deliver each service? In identifying that cost, be sure to understand the cost of the services you deliver for which you are not directly reimbursed, as well as your overhead, administrative costs, legal costs, insurance, employee benefits, mileage costs if your employees travel, etc. Please note that ABA provider practices vary broadly, and this is not an exhaustive list. It may be helpful to review the payor’s medical necessity criteria to identify burdensome administrative requirements or potential costs for which you may not be reimbursed.
  • Does the payor allow concurrent billing of 97153 and 97155?
  • Does the payor pay for or reimburse for an interpreter when the patient or patient’s family is Limited English Proficient? To understand more about provider requirements to ensure access to your services by patients and families who are Limited English Proficient, see The Diversity Is in the Details: Unintended Language Discrimination in the Practice of Applied Behavior Analysis.
  • Does the payor limit the number of hours for 97151? Payor assessment requirements vary, so be sure to understand how many hours you will likely spend on your patient’s intake and assessment and how that compares to the hours likely to be authorized under 97151.
  • Does the payor authorize 97152? Depending on your provider practice, this code may streamline and increase the cost-effectiveness of your assessment process.
  • Does the payor authorize 0373T for patients exhibiting destructive behaviors? If so, does that rate cover the cost of the service? This code requires a specially contrived environment and a minimum of 2 behavior technicians under the direction of a behavior analyst who is on site and interruptible. If the payor doesn’t authorize 0373T, be sure to have clear guidance about what the payor expects when you cannot accept a patient because of the additional support s/he requires.

Check back often as we identify other variables that may contribute to our understanding of sustainable rates.