Summary from Autism Roundtable
The purpose of this summary is to provide some notes and additional details regarding
issues and concerns brought up during the Autism Roundtable held at the Pentagon on
12/3/14. This summary is from notes taken by Megan Miller, M.S., BCBA who was
representing Navigation Behavioral Consulting, LLC and is also a member of the Behavior
Analysis Advocacy Network. If you would like to discuss information in this summary,
please contact Megan at: [email protected] or 850-348-5724. Information provided
in each table is based on notes taken by Megan Miller and should not be construed to
represent the Military Health System.
Response to Provider Questions
We greatly appreciate the time that the hosts of the meeting and representatives from the
Defense Health Agency, Regional Contractors, and TRICARE took to listen to concerns from
providers at the meeting. The information below provides a summary of questions and
answers that took place during the meeting that are directly relevant to providers.
Update on Changes Discussed at First Meeting
Noted Question
Noted Response
What is timeline for updates to the
The goal is to have the updated publication out
Tricare Operations Manual?
by the end of the month
Will the RBT requirement be extended?
The requirement for technicians to be
credentialed as RBT is extended to 12/31/2015
Can families only access one model: sole
No, families can access both types of service. If a
or tiered?
family is receiving sole they can change to tiered
at anytime.
Can there only be 1 BCBA on a case?
No, there should be one BCBA responsible for the
case but an additional BCBA can provide
consultation when necessary.
Can the language for discharge criteria be Yes, this is being changed in the updated manual.
changed?
What does “clinical necessity mean”?
Will be clarified in the manual.
How do you bill for team
A CPT code for this is being included in the
meetings/monthly clinics?
updated manual for quarterly meetings.
However, if more meetings are necessary it can
be requested.
Are there age limits?
No minimum or maximum age
How are authorizations being
This will be clarified in the updated TOM.
transitioned?
Families currently receiving services will be
grandfathered and do not need the diagnosis and
assessment paperwork. Authorizations will
automatically be issued for these families. If there
are concerns about disruption of service should
take to the Regional Contractor. If not able to
Noted Question
What is role of BCaBA?
What does “significant mean”?
Why do the treatment plans have to focus
on certain domains?
Is the supervision time for technicians
per beneficiary?
Noted Response
solve, they are suppose to escalate the concern.
When delegated by a BCBA and supervised by a
BCBA, BCaBAs can develop treatment plans and
provide supervision to technicians.
Will be deleting this from policy manual.
This language will be changed in the updated
manual. Intent was not to limit to those domains.
Yes. The supervision time is 5% minimum and a
20% maximum. If more than this is needed,
should consider the sole model.
Response to Provider Questions at Current Meeting
Noted Question
Why does the cost share not
accrue to the cap?
Noted Response
- Per DHA, services under
the tiered model are “not
medical care.”
- Other demonstrations
under TRICARE do allow all
costs to accrue to the
catastrophic cap, including
services and procedures are
not proven medical care.
Noted Action Being Taken
-Will be analyzing data from
RAND to make a decision.
-Leadership expects to have
an answer on this point by
the next roundtable meeting.
- Not intended to create a
barrier to care.
What is the standards of
care upon a new diagnosis.
Why is it taking so long to
credential providers,
-Waiting on data from RAND
to determine how to move
forward with this issue
A Navy Developmental
Pediatrician in attendance
was able to confirm a
minimum of 25 hours of ABA
therapy is prescribed upon a
new diagnosis along with
other services, including
speech, OT, and PT when
indicated.
-45-90 days is current
-Will be reviewing this
average
process and staffing with the
Noted Question
especially in the North?
How do we bill providers
using the new program?
Noted Response
*There was discussion about
how it is actually taking
longer than this and there is
no clarity for providers on
how to submit providers
with the new program.
*There was discussion about
how this taking so long,
leaves families on wait lists
for a longer time while
waiting for providers to be
credentialed.
-Submitted for new CPT
codes for BCaBAs and
Technicians but that won’t
happen yet
Noted Action Being Taken
Regional Contractors and
determining how to make
this happen faster.
-A uniform workaround will
be determined for all regions
-South and West indicated
that you bill under the
rendering provider who
provided the service for 1-1.
If it is a technician, you bill
under technician’s name;
BCaBA, under BCaBA name;
and BCBA under BCBA
name. If BCaBA is
performing tasks under
supervision of BCBA such as
supervision of technicians or
parent training, you bill
under the BCBA responsible
for the case.
Does supervision of
technicians provided by a
BCaBA count towards the
minimum 5% requirement?
Why haven’t claims been
paid yet for CACD claims
-North did not have an
answer.
Yes. This should be
delegated by the BCBA
responsible for the case and
billed under that BCBA.
The system should be
updated by Friday.
-Will look into why this is
taking so long.
Noted Question
billed in October?
Why are providers being
told that only 1 BCBA can
serve a client when
operating under the same
corporate practice? This is
not beneficial to the client
because standard of care
recommends working with
multiple providers for
generalization.
What outlet do we have for
communicating issues we
are experiencing with the
implementation of the new
plan?
Noted Response
Noted Action Being Taken
-This should not be
happening.
-Will provide clarification to
Regional Contractors.
-If you have ideas about
communication, email him:
[email protected]
-May set up a hotline.
-Providers deserve better
communication and this will
get fixed.
Additional Concerns/Questions
The following section provides more detail about some issues that were brought up during
the roundtable but did not allow for a long discussion. We are hoping that providing
leadership and representatives from DHA and Tricare with additional information on some
of these topics will continue to enhance everyone’s understanding of these issues. We are
extremely grateful for the dedication of everyone to providing access for military families
to top of the line autism treatment. If you have any questions about this information or
would like to discuss any of these issues in more detail, please contact Megan Miller:
[email protected] or 850-348-5724
Topic
Role of multiple BCBAs
Maximum supervision time
of 20%
Concerns
Additional
Information/Suggestions
The information provided
A doctoral level BCBA with
during the meeting seems to extensive research and
indicate that an additional
practitioner experience
BCBA can be used on a case
made an excellent point
when needed for additional
during the meeting that
consult.
limiting the providers who
can work with the child,
This does not address our
limits access to standard of
concern that many providers care for the child.
use a collaborative model
where multiple BCBAs
More clarification on this
(working under the same
issue is requested.
corporate practice) may
provide services to 1 child.
This is done for a variety of
reasons: logistics of
scheduling, expertise of the
BCBAs, input from multiple
sources, and to promote
generalization.
Currently, there are no limits There is research to indicate
to how much supervision
that the more supervision a
can be provided. It is
child receives, the more
important to note that many progress the child makes so
providers actually lose
it does not make sense that
money during supervised
this would be limited.
sessions because they are
billing for the BCBA but
paying the BCBA and the
tutor so when a higher
amount of supervision is
occurring, it is for good
reason.
Topic
Concerns
Additional
Information/Suggestions
Will exceptions to this be
made?
While we understand the
intent here, this also limits
the ability of the BCBA to
make decisions that are best
for the child. This limit
seems arbitrary and does
not coincide with published
research.
Cost shares
A BCBA may determine that
more supervision is needed
for a variety of reasons such
as: logistics of scheduling
(the child may benefit from a
BCBA but there is not one
available to provide the
hours needed so the decision
is made to use a technician
with heavy supervision) or
the technician is newer to
the field and requires more
supervision and training.
We understand that it is law
to have cost shares but is it
law to not allow them to
apply to the catastrophic
cap?
How is data being collected
on the families who cannot
access care due to the cost
limitations?
ABA is an “emerging
science”
Is there someone we can
refer families to contact
when they aren’t able to
afford services so that
accurate data can be
collected?
Is there someone we can
refer families to contact
when they are only able to
afford a low level of services
so that accurate data can be
collected?
This comment was made
The Association of
several times during the
Professional Behavior
meeting. We are very excited Analysts and Autism Speaks
that all stakeholders want to are well versed on this
include ABA but also think it subject and can provide very
Topic
Concerns
is appropriate to help
disseminate accurate
information regarding this
topic. ABA is not an
emerging science. The first
study using behavior
analysis with a child with
autism was conducted in
1964.
It was also noted that ABA
does not meet TRICARE
standards for evidencebased. This is contradictory
to the court ruling in Florida
regarding the medical
necessity of ABA that ruled
ABA is medically necessary,
the court ruling in Berge vs
the United States that ruled
ABA is medically necessary,
and other court rulings
throughout the country.
Most of the time this issue is
brought to the courts and
the evidence for and against
medical necessity are
weighed out by a third party
not responsible for covering
the treatment, it is ruled that
ABA is medically necessary.
This idea also contradicts
findings and endorsements
dating back to 1999 when
the United States Surgeon
General endorsed ABA as a
treatment for autism. In
2009, National Autism
Center’s Standards Project
recognized ABA as the only
treatment with sufficient
evidence to constitute an
Additional
Information/Suggestions
valuable resources to bring
everyone up to speed
regarding accurate
information about Applied
Behavior Analysis as a
science and treatment for
Autism.
Topic
Concerns
Additional
Information/Suggestions
established treatment for
autism. Additionally, ABA
has been endorsed as a
scientifically proven
treatment approach by
numerous organizations:
American Academy of
Neurology, American
Academy of Family
Pediatrics, American
Academy of Pediatrics,
American Academy of
Occupational Therapy
Association, American
Speech-Language Hearing
Association, Society for
Developmental and
Behavioral Pediatrics,
Autism Society of America,
National Institute of Child
Health & Human
Development, and National
Institute of Mental Health.
Credentialing providers
We recognize the
importance of a multidisciplinary approach but a
double standard is clearly in
place when Speech, OT, and
PT are indicated as
medically necessary for
autism treatment but ABA is
not. This is especially
concerning when ABA has
either met or is closest to
meeting the standards
discussed in the meeting
when considering the
different treatment options.
This was discussed at length
at the meeting but we are
concerned that the Regional
Contractors are not
We hope to see this issue
remedied quickly because it
causes even more delays to
accessing care for
Topic
Network Contracts from
MHN
Concerns
providing timely and
accurate information
regarding credentialing.
While we understand
regional contractors are
supposed to get discounts
for network providers, we
have concerns about how
MHN is going about the new
network contracts:
1. The maintenance of
the network is
extremely
disorganized. We
send in roster
updates and it takes
forever to get people
credentialed and/or
addresses are not
accurate in the
system.
2. They have not
contacted all network
providers about
network contract
changes.
3. The timing is not
appropriate. We are
already dealing with
all of the changes
from CACD and
increased time and
costs figuring out
these changes.
Providers are having
to cancel sessions to
figure out this new
program and are now
also expected to take
a rate cut.
4. No benefit has been
explained to us about
Additional
Information/Suggestions
beneficiaries.
In order to effectively build
the bridge between
providers, regional
contractors, Tricare, and
DHA, it is imperative to stop
issues like this from
happening. It is quite frankly
amazing that providers are
still working within the
network and seeing Tricare
families given the issues
they have dealt with the last
3 years (delays in payment,
delays in authorization to
provide services, delays in
credentialing, etc). Some
providers have already
stopped providing services
to Tricare clients because of
the uncertainty. NOW is not
the time for MHN to try to
change the contracts like
this.
Topic
General
Concerns
being in network.
Providers do not
need referrals as
most regions have
long wait lists for
services.
5. MHN is putting us in
a position to either
take a rate cut that
we were told would
not happen and is in
direct contradiction
to the Directive
(found here) put out
by DHA stating the
reimbursement rates
should continue to be
the same as they
were previously at
$125/hr for BCBAs
and $75/hr for
BCaBAS OR put the
cost onto our families
who will have to pay
a higher out of pocket
rate if we decide to go
out of network.
6. Current contracts
state we will be
reimbursed at 100%
and there has been
no clear reason given
to us about cutting
the rate as an
addendum with the
new program
starting.
We aim to provide the most
effective services to our
families. We would work for
free if we could. We want to
work with all parties
involved to help fix the
Additional
Information/Suggestions
Topic
Concerns
issues that have arisen and
smooth out this transition.
We are extremely grateful to
the Authorization and
Credentialing supervisors
we have interacted with in
the North Region who have
worked to clarify some of
our concerns. However,
tricare ensured there would
be a seamless transition and
that is not happening. There
is still time to turn this
around. Please contact us
and reach out to us as often
as you need to in order to
get updates about how this
new policy is actually being
implemented and what
impacts it is having on
providers and beneficiaries.
We want to talk to anyone
who will listen and can help
make this new program the
best program Tricare has
ever created for autism
treatment.
Additional
Information/Suggestions