Morphing from the Educational Model to the Medical Model: A Shift in Mind-Set and in Practice

Adding insurance to your basket of funding sources is one of the most important steps you’ll take to ensure the financial security and viability of your autism treatment practice. The basic business principal of not having all your eggs in one basket – or more simply put, not relying on a single funding source – is especially important for autism treatment providers. You are often reliant upon school districts and other government funded pots of money that, as history has shown, cannot be relied upon consistently over time. Furthermore, more and more states (now 33 in total) have successfully enacted autism insurance reform legislation, and efforts continue to be expended to ensure that behavioral health treatments are an integral part of the essential health benefits packages required by of the Patient Protection and Affordable Care Act (AKA Obama-Care).

In brief: If you’re not IN (READ: in-network with insurance carriers) you are going to be OUT (READ: out of business).

The process of preparing to work with health insurance companies involves much more than filling out and submitting a stack of applications and signing a bunch of contracts written in legal-eze. In order for autism treatment providers to be successful they need to undergo a major mind-set and documentation transformation from an educational model to the medical model. Remember, the reason health insurance policies are being required to cover autism diagnoses, assessments and treatments is because they are medically necessary. And, you, as a provider of these services, will only be paid for them if you are able to document that your care addresses those medically necessary needs per medical standards.

So, how do you actually show that can and do operate within the required medical model?

The first and most important step is to take a careful look at all of your paperwork: forms, policies, documents and templates. Do they comply with medical standards and requirements? What information are you missing? Are you getting a complete picture of the client as a patient rather than as a student? How do you “prove” supervision took place as it should? And what’s the method for documenting treatment plan changes?

Next you need to review your procedures: How are things actually done in practice? Are you properly ensuring the confidentiality of PHI (Private Health Information)? How about what’s on your tutors’ cellphones and laptops? How does a client transition from one level of care to the next?

Another essential component of working within the medical model involves your client files. A binder full of session data and notes will not be sufficient. You will need to create a comprehensive client file including intake and referral documentation, treatment and medical histories, client and family data as well as your own treatment history including supporting documentation regarding the treatment plan, progress on goals, and how and why you did (or did not do) what you did (or did not do).

Whether you are doing things correctly or not, and often for no apparent reason, you will be audited. The insurance companies will, at their discretion, require that you provide them with partial or complete client files as a way to ensure that you are doing what they are paying you to do in the way they require that you do it.

Ideally, by the time this happens, you will have morphed, both in your mind-set and in your documentation and practices to the medical model and associated standards. Haven’t made the shift yet? Don’t know what’s involved or what’s required? I’m here to help!

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