Navigating ABA Insurance and Funding in California

In this episode of Acorns to Oaks, Kristine and Sarah are joined by Nurture & Nature ABA’s Chief Operations Officer, Kevin Jackson, to discuss how ABA therapy is funded in California.

They break down private insurance, Medi-Cal, regional centers, autism diagnosis requirements, deductibles, co-insurance, authorizations, appeals, and what families should know when navigating access to care.

This conversation also explores the real world challenges families and providers face when insurance delays, denials, or funding changes interrupt services.

Transcript

SPEAKER_02 0:07

Welcome to Acorns to Oaks. I'm Christine Dixon, Board Certified Behavior Analyst. And I'm here, of course, with our executive clinical director, the phenomenal Sarah Moreau. Hello certified behavior analyst. And today we have a special guest. We are here with Nurture and Nature's Chief Operations Officer, Kevin Allen Jackson. Welcome, Kevin.

SPEAKER_00 0:32

Hello.

SPEAKER_02 0:33

Welcome. Glad to have you here today.

SPEAKER_00 0:35

Thank you so much.

SPEAKER_02 0:36

Especially on this very important topic. It is an important topic because it is about navigating ABA through insurance and funders. And often that can be quite challenging for our clients and actually quite heartbreaking as well. Kevin, how do families go about securing funding for ABA in California? What are their options?

SPEAKER_00 1:02

Well, the options are private insurance, um, Medi-Cal and the Regional Center. Uh for those of you who don't know what the regional center is, that's uh basically state-funded, California funded uh healthcare. Um and then of course there's private pay. If you want to pay out of your own pocket, you're free to do that as well.

SPEAKER_02 1:23

And each funder has a different requirement, but most require a psychological assessment as well as uh what?

SPEAKER_00 1:35

Well, it depends on the funding source, of course, right? So if you want to get your services funded by private insurance, private insurance will only fund those services if you have an autism diagnosis. So the first step would be to go to a child psychologist or uh behavioral pediatrician or any MD really or psychologist and get a psychological evaluation. And if it is determined that you have autism, uh they will recommend ABA. That's a pretty standard thing. And then uh your private insurance in that case will pay for it. And what's interesting is that in that exact scenario that I just described, your private insurance, if you have it, is the only funding source that will fund it, other than yourself. You're always welcome to fund yourself. But um yeah, if if you have private insurance and an autism diagnosis, then I think it's Obamacare, right? Since the ACA, they've had to cover it. And then, you know, any sort of secondary form of insurance will not cover it. If on the other hand you don't have uh a primary insurance, or more common, uh, you don't have an autism diagnosis, but a doctor has recommended that for whatever your situation is that you get um ABA treatment, that would be funded either through Medi-Cal or through the regional center.

SPEAKER_02 3:03

And the regional center is so absolutely phenomenal. I'm I'm just in love with the regional center. I've had the privilege, and you have too, Sarah, of working with them for close to two decades. One of the things is that you can get free psychological evaluations for children and uh individuals through the regional center uh by contacting them. And then there is a slew of laws, uh, the Lanterman Act and eligibility, which determines uh if you're eligible for regional center services. Um the people that work at the regional centers, how how amazing are they, Sarah?

SPEAKER_01 3:44

They have incredible, very dedicated staff that are looking out for the best interests of the client. And I think they have the benefit of not having to answer to a shareholder, where a lot of our private insurances do have to hold up that relationship.

SPEAKER_00 4:05

Yeah, I would I would say that without question, when the profit motive is removed, you tend to get people and companies and organizations that are more focused just on the care. Um that's for certain true with the regional center. Of course, it's true to an to a very large degree, uh, a lesser degree, I would say, than the regional center, but to a very large degree with Medi-Cal as well. Um, Medi-Cal has its own unique set of challenges. Uh, but yeah, if when when profit isn't a consideration, then the only thing left to really care about is the care.

SPEAKER_02 4:43

And one of the things over the past like four years is that the regional center has really gone to um personal, personal-centered planning. Person-centered planning, excuse me. The regional center has really gone to person-centered planning, where families really do get to pick amongst amazing clinical and recreational and social programs, adaptive skills. We have, I think, seven programs with the regional center. And families really do get to pick uh what they think is gonna work for them. And that's through the self-determination process. Is that right? Um, that that can be one way, yeah, through self-determination. So I just California has done it really right in supporting individuals with developmental disabilities because we've had so many clients that have moved out of state and have called and said, oh no, there's nothing really here. Yeah. I'm coming back to California. I know you had a client that moved to Florida, right? Yeah. And then quickly did a U-turn and came back. And that's not to say that uh Florida doesn't have any services. I just think California has been doing it for so long. And it's it really is inbred in the mission, I think, of the state to support the most vulnerable people.

SPEAKER_01 6:05

Yeah, it's really interesting if you think back on the history of how funding used to be granted. It used to only be regional center. And I thought there was a legal battle, I think with Kaiser. Do you know what I'm talking about?

SPEAKER_02 6:19

Well, there was a big law, SB 946, which uh the attorney general of California mandated insurance companies pay for ABA just for autism. Because before then, people don't realize if you had autism, they were like, there's nothing we can do. Yeah. Yeah. And what a horrible place to um to be. Absolutely. And I think one of the reasons why we really feel so passionate about this topic is because there is systemic racism in the world. And, you know, when you talk about systemic racism, you talk about healthcare and the discrepancies we see amongst races in affordability and getting care. Um, and we study that all the time. And I know California has put forth some amazing programs. Um, and Anthem has too for uh learning how to navigate those as clinicians. Um, but yeah, the regional center is just beyond wonderful. I don't even know. We did that event. Do you remember? Right. Um, we we painted how many people painted with us at that event?

SPEAKER_00 7:36

Oh, right. Um, hundreds probably, yeah.

SPEAKER_02 7:40

Yeah. And uh we met so many wonderful families that were uh being supported by the regional center. So uh, but we're really doing this specific episode because the funding can be so aggravating. Yeah. Yes, it can. It really can. I didn't have these wrinkles before I started working with the insurance companies, but it's rather heartbreaking um how these insurance companies treat these families sometimes.

SPEAKER_01 8:13

Well, and how difficult it is for families to navigate what insurance they should go with, what funding source will support them, and how to maintain access to services that they need.

SPEAKER_00 8:24

Yeah. And and just because this did come up in something you just said, I do want to, I do want to point out that at least from my um from my vantage point as an administrative person, I see much more of a class divide in in California in the availability of medical services than I do a racial one. Uh, I know that you being on the front lines of all that, you you get to see a whole bunch of good and bad things that I don't get to see. Um, but we have this system in California where uh the state makes sure that everybody who needs to be covered is covered, right? Um, and so that means that you've got the very, very wealthy people who don't need it and they're gonna get whatever they need to get. And then the state makes sure that the very, very poor who can't afford their own insurance get it. And then, as usual, with a lot of things that are uh part of the realities of our economy in this country, um it's the middle class that winds up being the ones who, ironically enough, get squeezed in terms of their access to care, right? Because they're wealthy enough to that they have to get their own private insurance or they do get their own private insurance. But then a lot of times decisions are made just based on the fact that they have these outrageous deductibles or these outrageous out-of-pocket maximums, which they can't cover themselves because they need that money for other things in their lives, but they're not poor enough to qualify for having those those co-pays, those, that cost sharing covered by the regional center or or what have you. Um and so it unfortunately what you see is that it really is uh it really is a class divide sort of thing that we're what that we're seeing. And by the way, it's not just in healthcare, that's a that's a much larger social issue that we're facing right now. But yeah.

SPEAKER_02 10:17

But you know, some of these coinsurances on these policies we've seen come through, because as behavior analysts, we have an ethical obligation before we enter into any um sort of treatment or contract, um, is to do a benefits check, to really do a cost-benefit analysis. And um some of these plans have like $25,000 individual co-pays. Right. And what that means is the first $25,000 of treatment is gonna be on the patient, the family to pay for. And that, I don't even know if I could afford that. Yeah, just honestly.

SPEAKER_00 10:59

Just to clear that up a little bit, you're not wrong, but that would be a deductible, right? So just for because this is something that's confusing to everybody, right? So the deductible is the part that you have to pay before everything else kicks in. So we do see these plans that will have very high deductibles, like say a $10,000 deductible. And that means that the first $10,000 of services that you get, not just for ABA, but all medical services, each year you're responsible for. And then let's just say that you have a $15,000 out-of-pocket um maximum and you have a, I don't know, a 20% coinsurance. So in that scenario, you're paying for the first $10,000. And then for the next $5,000 of services, you're paying 20% until you get to the 15,000 out-of-pocket maximum. And then finally, after that, the insurance company will cover it. And by the way, what I just described would be just the in-network benefit, right? They do in-network and out of network. So if you wind up going to an out-of-network, then that's a whole different deductible and a whole different out-of-pocket max.

SPEAKER_01 12:06

So and all in addition to the premium.

SPEAKER_00 12:08

All in addition to the premiums that you pay every month, yes.

SPEAKER_02 12:13

So because there are these real challenges that really pose barriers to treatment, um we decided that it would be of great benefit to the community to do a power ranking.

SPEAKER_00 12:28

Power ranking.

SPEAKER_02 12:29

Power ranking. So we wanted to discuss the uh top funders and the worst funders. Yes. And let's start with the worst funders. Number 10. Who is number 10 of the worst funders?

SPEAKER_00 12:49

I think you're gonna get a different answer depending on whether you're talking about it from a clinical perspective or administrative perspective.

SPEAKER_02 12:55

Oh, that's a good point. So let's split the list. Okay, we'll do the clinical and you can do the administrative.

SPEAKER_00 13:02

From an administrative standpoint, and it pains me to say this because I know that they do a lot of very good things. The two worst, I I don't even know if I I I would put them as like 10 and 10A. It's a tie uh that we've dealt with. By the way, this is just the ones that we've dealt with, and we haven't dealt with all of them, even though we've dealt with a lot of them. Um, the two worst, unfortunately, from an administrative standpoint, and for different reasons, are LA Care and IEHP, which is the Inland Empire Health Plan. Um, IEHP, and I'm and and I really, Sarah, because you live full-time in this area, I really want to hear your perspective on this. Um, IEHP has not led us into their network, and their reasoning is that they don't need any more behavior analysts. That's what they've told us. Um now, does it bother me that it took them a year and a half to get to that point where they even told us that? Sure. But more importantly, is just this notion that we got enough. We don't need any more behavior analysts.

SPEAKER_01 14:06

Did they really say that? Because that's I mean that's not reality, right?

SPEAKER_00 14:11

I'm speaking, I'm paraphrasing and you know, but that is effectively what they said.

SPEAKER_01 14:17

Yeah. So I am fortunate to live in the Big Bear area, which is a lovely community in the San Bernardino Mountains.

SPEAKER_00 14:24

Yes, and IEHP Inland Empire Health Plan means that it covers all of San Bernardino and Riverside counties. And so if you're not familiar with that area, it is a humongous swath of land that basically goes from the easternmost border of Los Angeles County all the way to the Arizona and I guess Nevada borders. I mean, it's a tremendously huge area.

SPEAKER_01 14:47

Yeah. And up in the bigger area, we are kind of an island because it's so separate from all the surrounding cities. Um and I have spoken to a lot of families that really struggle to access any sort of service at all.

unknown 15:02

Right.

SPEAKER_01 15:02

So I think it's very interesting that they came back with we have too many when what I'm constantly hearing is that we don't have enough.

SPEAKER_00 15:10

And not only that, it's not like our headquarters in uh San Bernardino is, you know, they're it's not like they're in one of the cities, right? We're not in San Bernardino or Riverside or Redlands or someplace like that. Our headquarters are in Big Bear Lake. I mean, it's in the mountain town. So it's not like they're looking at us and saying, oh, well, we don't need any more uh behavior analysts in San Bernardino. Maybe that's true. I mean, it's a big place, right? Maybe they do have enough. I doubt it, but maybe they do. But not in the mountain communities.

SPEAKER_01 15:44

Not in the mountain communities. And most people that are up there are on uh Medi-Cal IEHP. That's their that's their funder. So essentially what they're saying is these people don't need services when what I'm hearing from those people is yes, we do. So I'm not sure how to uh reconcile that problem.

SPEAKER_00 16:04

No, I don't, I mean, I the the the tragedy of it is that what that means is that if you either don't have an autism diagnosis or you're not wealthy enough to have private insurance, so you have to rely on Medi-Cal. That and you happen to live in one of those mountain communities, then you're just out of luck.

SPEAKER_02 16:28

Every time we get a call um from someone that wants services and they're funded by Inland Empire Health Plan, um, it's so sad. It's so sad. They want to work with us, we want to work with them. Um I don't I don't know of other behavior analysts up there, but I can see why they are 10 on your list. And who's 10 A?

SPEAKER_00 16:53

So 10A is LA care, and there's a there's there are significant caveats here because we actually are in network with uh with LA care. Um, and although, of course, I'm not a clinician, I do have a fair amount of interaction directly and indirectly with their with their UM department, the utilization management department, which is the department that makes decisions about we're going to approve this request or we're not or what have you. Everything that you guys were describing earlier about how there's these great people who work at, you know, at organizations like LA Care Medical, where it's, you know, or the regional center where it's not, uh, there isn't a profit motive in the same way. That's true of them. So LA care, in my experience, is filled with people who really do want to help people and really do care about making sure that providers are taken care of.

SPEAKER_02 17:47

So 10 is LA care and inland empire health plan. On the clinical side, what would be number 10, the worst fund?

SPEAKER_01 17:59

I really don't like the template for LA care. But is that number 10? What do you think? What's your number 10?

SPEAKER_02 18:06

They do have a pretty rigid 99-page progress report that they actually do read. It's surprising they read it because it's so rigid. Yeah. Um, but uh no, number 10 for me would they would be it would be the devil. It would be Magellan. Magellan is the absolute most horrendous, unethical insurer that I've ever worked with.

SPEAKER_01 18:36

You want to give us the top three reasons why?

SPEAKER_02 18:39

From a clinical perspective, uh, I think they don't care about their patients. I feel that I have so many feelings, actually. I'm overwhelmed with the fear. But, you know, they've hurt a lot of our clients. They've said, uh, you know, clients that had self-injurious behavior, they're like, yep, they're done with services. Like, we're not done yet. They're like, well, the par they really believe the parents can do the treatment. So they're like, the parents will take it over. And then the parents, you know, usually have a complete freakout. They cut people off mid-treatment. Uh, they they've done retroactive cuts, which is illegal. We've definitely gone to the Department of Insurance on that. I think their leadership is really poor in their clinical department. Um, I think uh, you know, they're very much out for cash.

SPEAKER_01 19:36

Yeah. They are very careful. Carry misalignment in terms of values and what the service is supposed to entail. Absolutely.

SPEAKER_00 19:47

And they and they uh um, except for some Medi-Cal uh companies, they were by far the lowest in terms of reimbursement rate.

SPEAKER_02 19:58

Yeah, they really they turn on their vendors um and providers. Uh they they act in ways like we didn't get a progress report. It's like we sent that progress report a month ago. It didn't have any data. It's like it had 60 graphs in that progress report, you know. So really the gaslighting of worst uh insurance denials, but the retroactive cutting of services, that's horrendous on both for the for the provider and for the patient, because it's like, yeah, you know how you've been getting services the last two months. Well, now you're sure not gonna, yeah, now you owe. And we never charge the patient if that happens, but they I've seen them cause a lot of serious harm. Yeah. Say, this patient needs a reduction in services. And um, we say very professionally, we disagree. Here's the data. Nope, it's happening. And then two weeks later, you know, when we're supposed to be in that home supporting that child who has safety issues, uh, that child breaks their leg from jumping down the stairs. And so, you know, I've written back to Magellan's clinical and said, She just broke her leg. And they said, Well, we'll reconsider. Take data on safety, unsafe measures. It's like she's sitting in a chair with a broken leg. So that baseline is not going to work. So um, I think Magellan really is the absolute worst insurer for my number 10. Do you agree?

SPEAKER_01 21:43

Or I do agree. Um in the past, we've had a lot of clients that were denied services. Um, I I think what I really don't like or dare I say, hate about it is um display. Dishonesty. Yeah. Just be up front. We don't want to pay. That's what it is.

SPEAKER_02 22:05

That's what the claim should say.

SPEAKER_01 22:07

We don't want to pay. Instead of you have no data. Yeah. Or the child doesn't need it anymore. Yeah. Right. The parents can handle it. Those are all untrue.

SPEAKER_02 22:16

Is that number 10 or is Blue Shield a Villinois number 10? Because they came back.

SPEAKER_00 22:24

I think you're forgetting a really big one, but go ahead.

SPEAKER_02 22:26

Oh. Blue Shield of Villanoid came back with a denial a couple years ago. And correct me if I'm wrong, Kev, but that denial was like, this child's not going to learn anything. Yeah. It's not possible for this child to learn anything else.

SPEAKER_00 22:41

Right.

SPEAKER_02 22:42

Isn't that what the denial kind of made reference to?

SPEAKER_00 22:45

I don't remember if that being Blue Shield a Villanoid, Blue Caster Shield a Villain, but it may have been.

SPEAKER_02 22:50

Oh yeah. And it was uh it was so sad because the the parents they work for did they worked for Disney, which you would think would have great insurance.

SPEAKER_00 23:00

I will I I do I do want to say though, in in their defense, if it's the one that I'm thinking of, that they did get to a point where the person on the phone basically just said, you know, you guys have been using the ABOS, and it's actually showing either no change or uh or going backwards, going in the wrong direction. Um, why don't you use this other diagnostic tool? And with the client who I know has Blue Cross Blue Shield of Illinois, we've done that. And it's a pain in the butt for you guys, I know, because it's a different diagnostic tool than you normally use in your reports. But as soon as we've done that, they've then approved the services.

SPEAKER_02 23:40

Well, as soon as they've done that and we've threatened to file with the California Department of Insurance, that goes a long way. So you can't forget, like, you know, the legal muscle. Yeah. It's but it came back with maximum treatment benefit reached for the denial of the services. And this was a child whose communication was massively impaired. He had so long to go to on his communication system to really thrive and be very functional. Yeah.

SPEAKER_01 24:12

What I will say about those norm-referenced surveys that they have us do, the ABOS and others, is that it is we are providing them with the data that we're that is our work. This is a separate thing, and I think it is designed for denial. It's just let me uh make you take this survey, and if it doesn't show the results that I want, even though that's not the data that we're doing day to day at home with the family, it's it's supposed to be kind of a bird's eye view of development, and that doesn't tell you much. It just gives you an opportunity to deny. And that is also dishonest, yeah, in my opinion.

SPEAKER_02 24:50

Yeah, going back to the norm reference, uh, you know, we've proven with things like the ABUS and the Vineland that it's really subjective. Yeah. That's very much parent-reported data. It's opinion-based data. Depends on the day they've had, you know, exactly. And so um with Cigna, we had a denial, and you know, we went through and we gave the the exact same ABAS to three different people, and it came out wildly different, wild variability um across developmental milestones. And I think that's really important. I know that the developmental um assessments are an insurance requirement. It's actually not a regional center requirement, but an insurance requirement. But those tests are, I think, crude measures. And that and that's what I believe. There's no inter-observer agreement. Um, you know, is that data really valid? And um, let's take the ABOS.

SPEAKER_01 25:54

What are the responses? Um, so they it's broken up into several categories, and they have always do it, sometimes do it, can't do it, don't know. Yeah. And then you never, yeah, yeah, yeah. And so then you you derive a score from that, and then it it's um, I think you're correct. It's a very crude measure.

SPEAKER_02 26:16

It's so crude that you use the same exact form for for five to twenty-one, right? Yeah. And um another thing is that I've given that assessment, that ABOS, to um families with different uh economic means. Sure. And um it's really funny because that is uh not all families are the same. Those assessments are not very culturally responsive, you know. I mean, some of the questions on the ABOS are, you know, do you sew your own clothes when you have a tear? Yeah. It's like, I don't know. Do you are we teaching sewing? I haven't, you know. Um, other questions are is like, do you carry enough money to buy a small purchase? Yeah, yeah. They're very strange. I I yeah, they're not very culturally responsive, they don't fit all families, and yet the insurance companies, they don't care if there's 25 elopements happening across the course of a month. If the ABOS says community safety is in the normal range, they'll exclude all that data. And as you know, Sarah, people with developmental disabilities have different levels of intelligence, and some are the smartest individuals we know. So they can carry money and they can do these things and they know all the rules of community safety. But yet when they get frustrated, they scratch their face or or engage in self-injurious behavior and like the ABOS doesn't capture them.

SPEAKER_01 27:55

No, what is being measured is not actually the work that we're doing. So, you know, it's it's sort of like I'll take your shoe size to see what jacket you should wear. It doesn't really um associate with the work that is being done and what the family needs and what the client needs. It's really, I think, focused on a measure that the insurance company can use to get the answer they want.

SPEAKER_02 28:19

Yeah. And actually, number nine on the worst following the horrific Magellan nine would be Cigna, because Cigna also used, and there was that big um break in article about uh the AI claims. Oh, and how despicable is that.

SPEAKER_00 28:37

What were the AI claims?

SPEAKER_02 28:39

That they were using AI algorithms to deny claims, right? I've also gotten letters from Cigna being like, this report doesn't meet medical necessity. It's like this is the report I've written for 15 years in the same format with the same graphs and the same data and the same operational definitions and the same baseline. And yet they're willing to send forth a rejection letter and be like, you have no baseline. It's like baseline is on these 30 pages. So you write back to them and say it's on page two and four and five and seven, and they're like, Yeah, you can appeal it. And it's like, oh my gosh. Like these are these wrinkles from these insurer companies.

SPEAKER_00 29:21

Well, just yeah, and that and by the way, uh, I'm sorry to no worries. Um that is actually, I think, a pretty important topic to discuss too, the whole uh notion of the appeals process, right? Because all right, let's say that services are authorized through February 28th, right? And so we've just submitted a report and they and they deny it for XYZ reasons, and then you guys have a peer review and they still deny it, and they say, well, you can you can go through an appeals process. That appeals process, if you're lucky, if you're lucky, is gonna take two months.

SPEAKER_03 29:54

Oh yeah.

SPEAKER_00 29:55

And so, well, what what are you supposed to do? You're putting both the client and the and the provider in a bind, right? Because now by the time you've gotten to that point, it's probably seven days maybe before the current authorization is done. And so are you supposed to stop services on March 1st, which would be completely unethical and would would cause would be very damaging to them, uh, to the to the consumer, of course. Um, or are you supposed to just risk it? Right? Yeah, we can't stop services, so we're just gonna keep going, which by the way is what we do, and I assume most ABA providers do, you just keep going because it's the right thing to do ethically, but then it puts you into a situation where you're potentially um in conflict with your client because either they're going to eventually say yes, and maybe, right? And then you've got the coverage. But if they say no, you have client services agreements with all these clients that says that say at the end of the day, you're the one who's responsible for the for the charges for these services.

SPEAKER_02 31:02

It's a horrible predicament, these insurance companies put people in it. Absolute horror. I mean, the parents are like, what am I gonna do? Like, and thank God we have the regional center to kind of like like go back on, but and I guess I wanna qualify that. When I say Cigna, we work with Evernorth Behavioral Health. And because I used to work with Cigna and they used to be great. No problems with Cigna. It was only when Cigna started outsourcing to Evernorth Behavioral Health, yeah, did things start going absolutely horrific. And I uh I don't know how those people sleep at night, what they do to patients, and um, they shouldn't be in healthcare. We were we're always so we see them at conferences and we always ask ourselves like, why did they become a BCBA to work for the insurance companies and deny people services? We always ask ourselves those questions because most phenomenal BCBAs that I know are like, I want to help my community, I want to help people, children. Um, and they're very passionate about that mission. But then there's these BCBAs that these insurance companies hire that just fight you. They're just there to fight you, to deny whatever you say. It's unbelievable.

SPEAKER_00 32:30

You know, with with Evernorth in particular, there is another sort of uh there's there's another kind of 800-pound gorilla in the room that I know you fought about. I don't know if you want to talk about that at all. Um, with the complete conflict of interest that they created um with that, well, I don't even remember what it was called, like this thing they wanted you to sign up for so you could become a preferred provider.

SPEAKER_02 32:56

Oh, yeah. So there's, you know, during the pandemic, uh Cygna slash Evernorth came to me and was like, you now have to be accredited through the Behavior Health Organization of Excellence. And remember the B H O C C E that's the cookie that you ate at Calab. Yeah, I was like, Sarah, cover your mouth.

SPEAKER_01 33:22

Yeah, don't eat a blue cookie at a conference. Yeah, we learned that. No blue cookies.

SPEAKER_02 33:26

That's bad news right there. Nobody wants to see that. Yeah. But um, you know, come to find out that the head clinician of Evernorth, his name is Dr. Darren Shush, was on uh the board of directors for the accreditation.

SPEAKER_03 33:43

Yeah.

SPEAKER_02 33:44

And it was during the pandemic when we were losing our minds, trying to hold our business together, trying to, you know, help as many people as possible. And um I said, no, I'm not going to give you $20. And this is a conflict of interest. And they got really mad. Didn't like that, huh? No, they didn't like that. I called that out. No.

SPEAKER_00 34:06

And didn't they but and didn't they say that you you have to get this accreditation so you can become a preferred provider? Yes. With the implication being that you weren't gonna get referrals anymore, yes, or you were gonna be way down the list for referrals or something like that.

SPEAKER_03 34:22

Yes.

SPEAKER_00 34:22

I mean, it's it's a completely unethical thing to do. My next company on the list, whether that's eight or nine or seven or whatever number, is has to be MHN.

SPEAKER_02 34:32

Yes, I agree.

SPEAKER_00 34:33

For those who don't know, it stands for mental health network, and it is the behavioral health arm, I think, just behavioral health, maybe meant all mental health of um of HealthNet.

SPEAKER_02 34:45

Yeah, they don't even seem to have the infrastructure to have proper professional communications. They they literally, I I agree with you. MHN is uh I thank God we're not a network with them, but they are a horror show to work with.

SPEAKER_00 34:59

Yeah, we um so it's a long story why we have one MHN client, but we're on a letter of agreement with them. And from a from an administrative standpoint, they are just a complete nightmare. Um they you can't submit your claims electronically, right? So you have to send in paper claims. Um paper claims. They have they have denied, I think. I mean, I'd have to look to know the exact percentage, but if if if someone told me, oh Kevin, it's 95%, they've denied, I wouldn't be surprised, they've denied 95% of our claims since September of 2024.

SPEAKER_01 35:42

Wow.

SPEAKER_00 35:43

And for all sorts of bananas reasons, right? Like the first thing was that when we so every every time you get a new authorization, you have to get a new letter of an agreement, which means you're signing a new contract with them every six months, which that on its own is bananas. But in when we were getting our new authorization in in uh September of 2024, and they sent us the letter of agreement like they normally do. Well, what they didn't tell us was that buried on page three of this agreement was a new billing mailing address. Oh so for six months we were sending our claims to the wrong address because they didn't alert us. Oh, by the way, this agreement that we just sent you that looks like the previous 50 agreements we sent you, we changed this one really important detail, but yeah, we're not gonna tell you. Um, so then we had to resubmit everything from those six months to the correct address. But then once we did that, that's actually when the insanity started, right? There so we use uh we use a software for all this that is very common in the industry in the uh ABA industry. Um, every single insurer gets gets uh billed using the same CMS 1500 form. There is no variation whatsoever. And I kid you not, we've probably had 35 or 40 claims denied because we're supposedly using the wrong form.

SPEAKER_02 37:10

There's only one form. There is only one form.

SPEAKER_00 37:13

But the denial reason is you're using a non-standard form.

SPEAKER_02 37:17

Wow, that really gets me grouped.

SPEAKER_00 37:19

And um so, yeah, so from an admin, and the the only other thing I'm gonna say, and I'm only saying this because I just I mean, I'll be honest about it. I'm saying it because I don't like them. It also happens to be true, is that they, you know, most of the companies will have some sort of um treatment request form that you have to fill out. And it's a pain in the butt, but it looks like a professionally made form and whatever, and you fill it out and it's no big deal. Their form, Christine, looks like a third grader made it. A third grader using like Windows, you know, Microsoft Word 95 and doing it poorly, right? I mean, it I mean, you know the form I'm talking about. It just I mean, I can't even believe an organization that's supposed to be this professional, huge corporation is putting out something that it looks like my three-year-old cousin could have made.

SPEAKER_02 38:10

Wow.

SPEAKER_00 38:10

And probably better.

SPEAKER_02 38:12

Okay, number seven on the insurance companies.

SPEAKER_01 38:19

Can can I just say any insurance company that requires the ABOS? Now I'm all fired up about it now that we talked about it.

SPEAKER_00 38:24

Oh, and by the way, we're not just talking about insurance companies here, we're talking about funding sources. Remember that.

SPEAKER_01 38:30

Yeah, true.

SPEAKER_00 38:31

Because eventually we have to work our way down to number one, and number one's pretty good.

SPEAKER_02 38:35

Yeah, yeah. Number seven for me, they're newer to us, so I that's the only reason why they fall number seven is Blue Shield of California. Yeah. Yeah. So they're new to us. We're just starting. Um, so they're num, they're my number seven. Kev, who's your number seven for it?

SPEAKER_00 38:54

Well, I'll talk, I I can talk about Blue Shield of California a little bit because um I've had both positive and negative experiences with them. Um they are um I I'll just say this that they came to us, and I don't know if you guys know this, but in California at least, until December 31st of last year, all behavior behavioral health for Blue Shield of California cons uh consumers was farmed out to Magellan. Right? They decided for some reason Blue Shield of California did, and maybe it has something to do with the things that that Christine and Sarah were talking about. They decided to end their relationship, at least in California, with with Magellan.

SPEAKER_01 39:37

Yay, and so now behavioral health.

SPEAKER_00 39:41

Um, you know, behavioral health goes directly through Blue Shield of California, just like most other procedures and services do. Um, and what was amazing to me about that process is that they contacted us. They reached, they didn't, it is very typical for insurance companies in my experience to just put something out there, not be specific about where it's directed and expect you to somehow know that it exists, right? But they didn't do that at all. They reached out to us. Um, and the guy who I've been dealing with, who is our representative there in the contracting department, seems genuine in his excitement to have ABA providers under the Blue Shield of California fold now.

SPEAKER_01 40:22

He does, it's true.

SPEAKER_00 40:22

Um, we negotiated a new, we had to negotiate a new contract. I will say that they were very fair. You can say that I can't say the I know I can't talk about rates, but what I can say is that they were cognizant of where the industry is, and they they applied that knowledge to the our contract discussions.

SPEAKER_02 40:45

They have the potential to be number one on my list if they you know keep working. They keep it up, yes. So uh number six for me would be Kaiser. Ah, Kaiser. Kaiser Permanente. Yeah, yeah. I I do like Kaiser. Um they've been really good to our clients. Uh, we've had long-term uh contracts, they've never pushed for decreases. So Kaiser to me is uh A-O-K.

SPEAKER_00 41:15

We have some doozies that we haven't spoken about yet. From an administrative standpoint, Kaiser has been great. Um I'm not a huge fan of how they have chosen to deal with anybody who has Kaiser knows this, right? Like they have most of the things in-house, but then there's there's certain things that they designate as specialty medicine, like acupuncture and and behavioral health falls into that category that they deal with in a different way outside of their you know, their normal framework. And the way they've chosen to do it, at least in Southern California, I don't know if this is true in Northern California or anywhere else that they are, is they they decided to contract with one company, right? And they have this system that basically, and by the way, they don't do that with other forms of specialty health. Like for for acupuncture, by the way, and I have Kaiser and I love Kaiser, Kaiser saved my life, right? Um, and at one point I had to get acupuncture, and they give you a list, just like you normally would. Here's all the acupuncturists that we work with. Um, for behavioral health, for some reason, they don't do that. They have some sort of an agreement. I'm not gonna say the name of the company. If you want to, you can. And they force everybody to go through that company, no matter who they want to work with, until it becomes clear that either they don't the, you know, the the consumer has tried that company and they don't like them, or that company just doesn't have capacity for them. And then they allow them, then what they come to us, they'll make referrals to companies like us in that case. And once they get to us, the experience is very positive.

SPEAKER_02 42:50

Yeah, they're they're coming out of uh something that they really didn't like into something that works. So our you know, the I think uh the clients that we've seen under Kaiser for ABA, it's been a really positive experience.

SPEAKER_00 43:05

Yeah, and the and our dealings with them, like that's what I'm saying, is like like once we get to that point where they make the referral to us, everything from you know, you're talking about the clinical side from the administrative side is very positive. They they pay fair rates, they don't mess around, they get you the contracts that you need, um, they pay their claims on time. There, there's not a lot of nonsense with denied claims. Um they, you know, they provide you authorization. The the UM department there, I have to say, of all the commercial insurers, those people really care. I mean, at least they or either that or they uh they put up a good act, but they they really seem to work hard and care. And I've never had anything but positive interactions with them, with the UM people.

SPEAKER_02 43:53

Okay, who's next on your list? What number is?

SPEAKER_00 43:56

I can't even believe you haven't spoken about Anthem yet. And Carol. On in that whole mess.

SPEAKER_01 44:01

Well, maybe before we move on to the top five, we should talk about what parents can do if they're facing an appeal. Oh, yeah. What they can do if they're searching for replacement funding.

SPEAKER_03 44:14

Yeah.

SPEAKER_01 44:14

Um, because we're talking a lot about like the provider side.

SPEAKER_02 44:17

I don't know that I'm not sure how much parents understand about I think they should understand because when the insurer comes down and says, nope, um, those parents, they have to navigate the system, which is a nightmare. Um, one thing that I think parents need to know is that if you commit to a provider and then you don't like that provider, and you go toward another provider like us, and we try to pull an authorization, but you're already committed to another provider, they will deny that. So if you want to change providers, you actually have to call it in.

SPEAKER_00 44:53

Um, you have to tell them to terminate the authorization with the other provider.

SPEAKER_02 44:58

Yeah. Okay.

SPEAKER_00 44:58

They won't authorize the same service with two different providers at the same time. Yeah. They just won't do it.

SPEAKER_02 45:03

I think number five for me is Anthem, Carolon, Elevents, whatever the the Yeah. I I used to love Anthem. They used to be my number one. We had a great rep that we worked with. There was never any issues.

SPEAKER_00 45:18

Um then the mergers happened.

SPEAKER_02 45:21

And then they merged, and um, and uh it's really that has been a challenge uh for clients in general. So Carolon is my number five.

SPEAKER_00 45:32

You know, they had this merger, and that's fine. Mergers happen. Um but in one of the conflicts that that obviously creates in the insurance industry is that Carolon is a company that has their network of providers in Anthem of California, Anthem Blue Cross of California is a um, or I think it's just technically called Anthem Blue Cross, they have a network of their providers, right? And when they merged, they didn't merge the networks, at least not in California. We were told for like two years that the problem was, well, we're just still working through the merger, but eventually it's all what going to be one group, you know, one group of providers, right? But what the ex what our experience has been is depending on the nature of your your individual plan, what our experience has been is either they're like, nope, this is a Carol, you know, even though your card says Anthem, this is a Carolon client, and you know, they have to go through the Carolon network, or you have to get some sort of special, you know, out-of-network agreement, um, letter of agreement, which is a pain in the butt and which they don't want to do, and which frankly providers don't want to have to do either, because it's a whole bunch of extra unnecessary administrative work that all it does is put stress on the provider and the and the client, right? And it it denies the client the thing that they need the most, which is just, I just want to go to the doctor and get the care that I need or the provider and get the care that I need, right?

SPEAKER_02 46:56

Agreed. I I I do think the merger has been really sloppy that way and upsetting, but I don't think anything was more upsetting than I think it was uh 2021 during the pandemic when Anthem sent all of ABA a letter saying we're gonna cut your rate by 40%. And um, I gotta give it up to the ABA community and Calaba.

SPEAKER_03 47:21

Yeah.

SPEAKER_02 47:21

Um, because they rallied and we we all said, fine, we're gonna dump all our clients and then they backed down. But that was uh Yeah, I forgot about that part. That was really scary. That that brought Anthem from number one in my book because I was having a love affair with Anthem the first five years I was, you know, in practice, but uh that really brought them down to number five. Yeah.

unknown 47:45

Yeah.

SPEAKER_02 47:46

I who's your number four?

SPEAKER_00 47:48

The only two that that I have left really on my list are Aetna and then the regional center.

SPEAKER_02 47:54

Yeah, I think Aetna comes in strong at number four. I think they're the best insurer to work with. I I have had no problems with Aetna. They they seem to genuinely care about their patients. Um and we've had a lot of long-term uh outcomes and success with Aetna. Yeah, and let's rank the regional centers in order.

SPEAKER_00 48:19

Well, just the ones that we deal with regularly, of course, right? I mean, the two major ones that we deal with are North Los Angeles County and West Side, which is not to say we don't deal with others. We've dealt with Landerman, we've dealt with Kern, Kern, we've dealt with San Gabriel Pomona, Eastern Los Angeles, South Central Los Angeles. Um, we're starting to deal with Tri-Counties, we're starting to deal with Inland Regional Center. Um, but by far our most interactions have been with Enlark, that's North Los Angeles County Regional Center and West Side Regional Center. And you know that they both have strengths and weaknesses. Um I will say that if I if I was forced to, I would put um I would put Enlark as my number one.

SPEAKER_01 49:08

What about you? Who would be your number? I also think it would be Enlark. I I I feel like they are responsive. Um, it's easy to communicate with them. Yeah. Um they're quick. They're quick. Yeah.

SPEAKER_00 49:23

They seem to be problem solvers. I mean, maybe we just have more interactions with them, so we have more opportunities to see the positive things. But from a consumer standpoint, um, I see them addressing consumer needs all the time. You know, I mean, we did we have a we have a situation with um a client right now, actually, who was on Medi-Cal. And for some reason this happens every once in a while, where something will go wrong in the system and someone will just fall off of their Medi-Cal plan. And so all of a sudden, without some a lot of times, without them even knowing, they don't, they suddenly don't have coverage, right? And if if you catch it soon enough, usually the regional center will step in and will help you, you know, uh deal with those gaps in coverage. Because otherwise it just creates stress on the you know, on the providers, certainly, because they need to be paid for their work and it creates stress on the clients because they don't want to be, I can't afford this, but I need it, right? Um, and they just step in and they solve that those problems. And you see them do things like that all the time.

SPEAKER_02 50:28

Yeah, Nlark's pretty great. They're they're my number one. West Side Regional Center is my number two. I think North LA regional center has more structure. Um, they have a broader reach, they're the biggest regional center. West Side is great. Um, West Side is a little bit more sleepy in terms of doing the paperwork and getting things over.

SPEAKER_01 50:54

I think also clients just getting in to the West Side is harder. I do think so. It's a bit of a backup, maybe.

SPEAKER_02 51:01

Yeah, I think so. It is a bit of a backup. Things take longer over at the West Side.

SPEAKER_00 51:06

Well, certain things don't take longer, too. But most of the things that impact consumers, you're correct. But from an administrative standpoint, um, there are certain things that West Side does better, you know.

SPEAKER_02 51:19

Yeah, and number three, I would have to give it up to Tri-Counties. Tri-County is the vendorization process with Brandon. Has really fast. Really fast. They're very organized, they know what they want, and and um that they've been a pleasure to work with so far thus far. Yeah. So that's it. That's all.

SPEAKER_00 51:38

That is the most jacked up power rankings ever. Power rankings.

SPEAKER_02 51:43

Power rankings.

unknown 51:45

Power rankings.

SPEAKER_03 51:47

Funders.

SPEAKER_01 51:50

And on that note, thanks for joining us for another exciting episode of Acorns to Oaks. If you have questions about funders, please feel free to reach out. We'd be happy to help you as much as we can and be sure to subscribe to that button. You know the one I'm talking about.