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ABA Therapy Credentialing—6 Steps to Surviving an Optum/UBH Audit

Surviving an audit by Optum Insurance

ABA Therapy Credentialing—6 Steps to Surviving an Optum/UBH Audit

Tips for BCBAs and ABA Therapy providers applying for In Network status with Optum/UBH Insurance.

As we noted in our previous credentialing blog, each insurance company has its own process for credentialing as In Network for ABA Therapists and ABA Therapy providers. This week, our guest blogger, Sarah Schmitz of Comprehensive Billing Consultants, will talk specifically about Optum/UBH (United Behavioral Health) Insurance and the audit process they require for credentialing. Grab some sticky notes, sticky tabs, a highlighter, and a pencil—you will likely need to do some erasing—and let’s get you organized. Use these steps to help prepare for the audit process and it should make credentialing with Optum/UBH much easier.

Note: Being In Network with Optum/UBH also covers plans with ABA services covered under the medical side of a United plan.

Optum/UBH Insurance Audit Process:

Depending on whether your agency will see your clients (patients) in a clinic setting or in the “Home, Community” setting, the audit process will either involve a visit to your clinic from an audit reviewer for an onsite audit or will be done through electronic means.

For an onsite audit, the audit reviewer will be looking for all of the facility site audit requirements listed in the Facility Site toolkit as well as the Medical Records requirements listed in the ABA Records toolkit and the Agency Policy and Procedure requirements listed in the ABA Agency toolkit.

If your agency will only see your clients (patients) in the “Home, Community” setting the audit is done by sending the ABA Record and ABA Agency toolkits to the audit reviewer via email, Dropbox, or your preferred method for sharing documents.

1—Initiate an application with Optum/UBH and print out your “tool kits.”

The first step is, of course, to apply with Optum/UBH. Once they receive your application, they will send you a “tool kit” for each audit you are required to have per your facility or individual needs. These tool kits are checklists of items that Optum/UBH requires. Print them out and staple each tool kit separately. It’s not a bad idea to keep an extra copy handy for scribbling notes, etc. You can always transfer anything messy to a final copy.

2—Get all of your Agency Policy & Procedures together in one place.

The toolkits ask for each policy/procedure that is required to pass the audit. So if you don’t have a policy already in place you are required to do so before submitting the documents to the audit reviewer.

Some policies and procedures documents required:

Staff: You will need an Employee Handbook which includes expectations of staff and guidelines to follow, job descriptions, training requirements, HR procedures and staffing background requirements, and staff responsibilities to the families and to the company. The agency responsibilities to their staff includes annual HIPPA training and OSHA training and making sure all staff and the agency meet all the BACB board and state guidelines for providing ABA therapy. Adopting these laws and guidelines into your agency policies and procedures will also insure you are meeting all the requirements for state, BACB, and Optum/UBH. Documentation requirements of each session, direct services, parent training, supervision sessions, assessments, etc., should also be included in the handbook.

Family and patients: You will also need a Family Handbook which incudes expectations for the families receiving your services, for example, what the families will be required to do or not do during your services, sick policies (when should the family cancel services if the child is sick and whom they should contact). The Family Handbook should also include what the family can expect from your company, the expectation of the relationship with your company, staff, and the family. It should clearly notify the family that the company has an obligation to report anyone that has been identified of neglecting or abusing the patient (child). It should also include how to file a complaint how and to whom in your agency they can go to for this. Emergency policies, crisis policies, HIPPA consent forms, and consent for services forms, to name a few, are also to be included.

3—Select a client file (which can be redacted) to remove all personal info for the ABA therapy record audit.

Optum/UBH requires very specific elements to be present in your ABA Medical Records, The ABA Record Audit Tool Kit lists each requirement for completing this part of the audit.  Redacting the file allows Optum/UBH’s Audit reviewer to view the ABA Medical Record without breaking any HIPPA Laws. If you have not started to see patients yet in your agency you can use your record template (a blank record that will have all of the required elements in the record, e.g., Name, DOB, ID#, Dx, and so on). Having one that you have already completed will allow the reviewer to get a good indication of your documentation and whether it meets their level of completeness and requirements.

You will need to show your intake paperwork, assessment report, session notes, and a discharge report.

4—Have OSHA & HIPAA Policy & Procedures included in your handbook even if you don’t think it pertains to your situation. IT IS REQUIRED!

Review HIPPA policies and laws and make sure your agency policies stay current with these laws. The same goes for OSHA laws and policies (in a clinic setting you must meet all OSHA requirements on site), e.g., posters, eyewash stations, and the OSHA compliance book. If you don’t not have a “Clinic” setting, as an employer you are still required to make sure your staff has access to the required documents and policies. I suggest having these in an electronic form for staff to access remotely as needed.

5—Do one toolkit at a time if you have more than one to complete.

Do one line item at a time. Start from the beginning, gather what you need to answer completely, and just work your way to the end in this fashion. If you skip around, you may miss something and you absolutely need to have each line filled out properly.

Use your sticky notes for title and page references. As you find the answers for each line item in the tool kit, use your sticky notes to write down the name of the manual/document and the page # on which you found the answer to the item on the toolkit question. You can use these to reference your source when rechecking and comparing multiple tool kits.

Tab anything that you are missing and come back to it. If you can’t find the answer you need in a timely manner, mark it clearly with a sticky note and tab so that you can easily see that you still need to complete a portion. Continue on and come back to the missing sections later.

Move on to the second audit only after you have completed the first. There may be overlapping questions per audit, but if you have the first tool kit sticky noted and tabbed completely, you will easily be able to use these references to find the specific answer you need for the second tool kit.

6—The Optum/UBH Provider Express website has resources that are extremely helpful. Utilize the web resources as needed.

These links take you right to ProviderExpress.com, where you will find the toolkits along with any other ABA therapy information you may need about providing services to an Optum/UBH member.

Once you have all your required documents together and your toolkits are completed, you are ready to move forward with the audit—be sure that you have indeed completed all of the toolkits and other documentation before moving forward. Contact the Optum/UBH network representative assigned to your case. They will schedule the onsite audit, so you will want to keep your documents together and ready for the audit review. If you are doing the electronic review, you and the network contact may work out the details for sending the documents to the audit reviewer at this time.

In many ways, the application and audit process is a great tool for helping you get your policies and procedures organized and implemented. If you have any questions, let us know how we can help.