Wild Wild West

The ABA field will be going through drastic changes over the next 5-10 years. Right now, we’re kind of in the Wild West. Think about the optics of the ABA field – an individual with about 1-2 weeks of training (in some cases none) goes out and provides a medically necessary service under the supervision of someone who isn’t always licensed. In what other healthcare industry is this allowed? The barrier of entry to enter an ABA business is so low (get an EIN number, hire a BCBA, and you’re ready to go!) yet the risk is incredibly high. What we do now as agency owners will shape and drive the regulations of this industry for years to come. As you’re thinking about starting a business, please think about how your decisions could impact other providers in the future.

Here are some tips to building a solid/reputable agency:

• Recommend hours based on the client’s needs. I see too many providers recommending 40 hours for each client. Do a thorough assessment and recommend hours based on the client’s skill deficits and behavior excesses. Include parents in your treatment plan and work hard to put yourself out of a job. Provide excellent high quality services based on evidence based practices. Hit up your colleagues if you don’t know the answer to a question.

• Provide RBT certification for your staff (or encourage them to do so). Yes, I know that many BCBAs have their criticisms with the RBT credential, but it’s the currently the one of the only credentials out there for behavior technicians and we need to do whatever we can to legitimize our field.

• Work with other providers and don’t be an asshole. Our field is filled with misconceptions and it doesn’t help if we don’t collaborate or look down at other fields. SLPs, OTs, developmental pediatricians. I’ll talk about this in another post, but we’re getting hammered by the “anti-ABA” folks who believe that ABA is harmful, dangerous, and cold. I see new BCBAs on facebook groups get treated like shit by other more experienced BCBAs (of course it’s not the norm) for asking simple questions. We need to build a warm welcoming environment where discussion and dialogue is encouraged.

• You don’t know everything. And neither do I which is completely OK. We don’t know anything and everything there is about autism, child development, behavior.  Let’s work together and make a fucking difference in this world. BCBAs dont have training in child development, special education, psychopathology, DSM..etc. Yet, some of us pretend as if we’re the next best thing to sliced bread. Let’s put our egos down for a second, understand our scope of practice, and do what’s right for our clients.

• Put your staff first and your clients a close second. Wait, I thought we were supposed to be here for the clients?! Yes, we are. Which is why you need to take care of your staff FIRST. If you aren’t treating your staff well, your clients are not going to be treated well. How can you make sure your taking care of your staff? Pay them well. Treat them well. Listen to their concerns. Make sure they are WELL prepared for their jobs (train, train, train). Provide them with supervision. Make sure they are not spending a shitload of time on admin work. Provide a culture and space where they can voice their opinions. Retaining RBTs isn’t rocket science, a lot of it has to do with how you treat your staff.

• Don’t forget why you’re doing this. Ultimately, we all got into this field because we love helping people. There are many other careers out there that pay more and have less stress. With that said, if you start an ABA business, make sure you understand that you will need to make business decisions in addition to clinical decisions – you now own a clinical business. Sorry guys, passion alone isn’t going to pay your bills. This can be difficult for a lot of people to understand. You need to make a profit in order to continue providing services so there is nothing wrong with making a profit in your business. Just remember why you do what do you do at all times.

Feel free to leave a comment if there are specific topics you would like me to discuss!

Payroll. Because you shouldn’t f@#* with other people’s money.

I thought I would do a blog post on payroll. One of the big questions I always get is “how much money do I need to start an ABA business”. As I’ve mentioned in my previous posts, you don’t need that much money to start an ABA business if you’re doing it solo and you have some work on the side (working as a part-time BCBA for another company). However, if you plan on hiring RBTs, it’s a whole different ballgame.

Let’s say you pay your RBT $20/hour and they’re on a case for 10 hours/week. That’s $200/week you’ll be paying your RBT. Now let’s say you don’t get paid until 60 days by an insurance company who funds the client’s services. That’s about $1600 you’ll need (excluding taxes, benefits..etc) for one RBT. Multiply that by however RBTs you need. That’s obviously not including all of the other overhead costs (tablets, materials..etc).

I would actually err on the side of caution and say you need about 3 months worth of pay. So in the above example you would need about $4800 for 1 RBT. Depending on your state taxes and benefits you offer, you could be looking at paying close to $5000-5500 for 1 RBT for 3 months of work. Regardless of whether you get paid by the insurance company or not, you will have to pay your staff. So it’s really important to have enough money to cover payroll in the event you don’t get paid by the insurance company. I suggest getting a small business loan or saving up money if you plan to hire your employees and forecast your needs appropriately.

Besides the money part of payroll, one of the most common mistakes I see new ABA agency owners make is not considering state payroll laws. For example, in California it’s essentially required that people get paid for mileage and drive time in between clients, but I still see organizations who don’t pay their staff for this. Also, California has very specific OT and paid break rules which can be tough to navigate manually (hence, I always recommend a practice management software no matter what your size is)  It’s really important that you have a very thorough understanding of labor and payroll laws in your state. I highly recommend working with an HR or Labor Law specialist to help craft payroll policies.

Let me make it super clear for anyone who is thinking about classifiying RBTs (or any of their other staff) as independent contractors…..DON’T! RBTs are not independent contractors and those payroll taxes you’ll be saving short term will come back to bite you in the ass when the IRS comes after you for misclassifying employees. There have been many ABA agencies who have had the IRS come after them – so just don’t do it. Make everyone a W2 employee and you’ll be able to sleep better at night.

Payroll can be very difficult to manage and the last thing you want to do is be sued by a employee because you didn’t pay them correctly. There a lot of great practice management softwares out there that can help you with billing, payroll, scheduling. Check out Theralytics which is a super user friendly and affordable platform – http://www.theralytics.net or email them at info@theralytics.net.

Billing – Getting paid legally.

Alright so you’re a big shot BCBA with your own company. You’re in network with a few insurance companies and you receive your first referral. Great! I’m assuming you have all the appropriate state licenses, workers comp insurance, liability insurance, payroll…etc etc all figured out. If not, get on it!

Ok, first you have to understand that medical billing is a whole different ball game. If you think it’s simply sending a bill and getting paid with a smile each time…it’s not! As I mentioned in my previous posts, there are times where you have to wait 30-60 days to receive payment for services (sometimes more, sometimes less). Paying your employees before you are paid is just the reality of the situation. However, if you run into billing mistakes, it can be even costlier.

First, you need to make the right investments to ensure you’re setting yourself up for success. There are several errors that can occur during billing and you need to make sure you are positioning yourself to succeed. The best way to do this is move to an electronic/paperless system. Billing is already a PITA, why make it more complicated by worrying about paper documents? There are several practice management systems out there that can make billing (in addition to scheduling and payroll) a piece of cake. I understand it’s more costly to have these systems, but the lack of stress is well worth it. These systems have built in scheduling/billing features that make the billing side of ABA much easier. In the event of an audit, it’s much easier to pull from an electronic system rather than dig through paper files. In addition to practice management software, you should invest in tablets (androids/iPad) for your staff. Your staff should use tablets to render their times in the client’s home, write their SOAP notes, as well as obtain parent signatures. It is imperative that your staff are obtaining signatures of the responsible adult/legal guardian each time your staff bills for a service.

Alright so your paperless now. #welcometothe21stcentury #treesrcool. What next?

Understand billing. Understand billing. Understanding billing. Did I mention you should understand billing? Read this next part very carefully – tattoo it on your arm if you have to. Do not bill a code if you are not sure what the code allows you to bill for. You should know EXACTLY what that CPT code allows you to bill for. Ask your provider rep, read your contracts, get every damn thing in writing. This isn’t a joke – this is serious shit. Fraudulent billing is a VERY serious crime that can lead to legal and financial consequences. Make sure you get clarification regarding codes from the insurance company in writing and you’re working with someone who has experience in medical/ABA billing. Let me give you an example of some of the complications:

• Do you know about rounding rules? If not, you better go back and read your contracts. Payers have their own guidelines on how to round your units. For example….if 1 unit = 15 minutes and your BT works 5 minutes, is that billable? (answer is probably no, but you need to know why and point to the documentation). Read. Your. Contracts.
• Is it OK to bill for the Behavior Technician and BCBA at the same time? Can the supervision time be used for indirect supervision? What’s the code for parent training? What’s the treatment planning code? What type of documentation does the payer require before you bill for the service? These (plus many many more) are questions that you need to get answers to before you bill.
• Again, do not bill codes without understanding what you’re billing for.

Lastly, the question I get quite often is “should I outsource my billing or should I handle it internally?”. My advice is to learn the ins and outs, but I absolutely recommend working with an expert, especially if this is new to you. If you need assistance, there are several ABA billing companies that can assist in billing for you. They’ll charge a percentage of your receivables (amount billed) or a flat fee depending on their business model. Once you get to a certain size, it would probably make sense to hire a biller.

TLDR; Read your contracts. Work with an expert. Know your billing guidelines for each payer.

Mo’ Money Mo’ Problems

Being in the ABA field can be challenging (but SUPER rewarding)….long hours, difficult clients, being isolated from other people, and driving, driving, and more driving. At the end of the day, any reasonable person expects them to be paid for their hard work right? Right! If you’re working for an ABA agency, you might have it better than you think. You’re getting paid for your work regardless if the company gets paid or not (switch companies ASAP if you don’t!).

You’ve mentally prepared yourself to start an agency, but have you financially prepared yourself? Those BCBA letters and impressive research articles are not going to save you when you don’t have enough $$ to run payroll. What do you need to do? It all depends on your situation. However, you’ll definitely some money to start your business.

You’ll need to have money to startup your business. Things like:

1. Advertising
2. Business cards
3. P.O. Box/Virtual Office (Please don’t use your home address when contracting with insurance companies)
4. Licensing fees
5. Work comp insurance
6. Liability insurance
7. Practice management software
8. Data collection software (go paperless right off the bat – it’s a lot easier)
9. Accountant
10. Business attorney/HR expert (don’t mess with labor laws)
11. HIPAA compliant software
12. Cell phone
13. Devices to go paperless (android tablets are a good option)
14. Initial payroll costs
    1. This can be reduced if you do the BCBA, and behavior technician work at the beginning. It can be stressful, but it saves on initial payroll costs.
15. And much, much, more.

Notice I didn’t add your salary on there. That’s because you’re not getting paid for a while! Either have money saved up, work out something with your employer that allows you to work part-time, or quit your job and move to a 1099/Contractor position. A lot of people will find a 1099 job that allows them to start their own ABA business. The 1099 job provides flexibility and allows you to pay yourself while you get your business started.

I don’t encourage loans/credit cards, but sometimes that’s your only option. Just make sure you understand your risks very well. There is always a chance your business may not take off OR you just hate dealing with the business side of ABA.

Payroll costs are much more than the hourly rate you are paying your employees. You have to factor in (some of these are specific to California, your state may have different payroll costs):

1. Employer payroll taxes. That’s right – your employer pays a portion of your payroll taxes. If you are a 1099 you are responsible for those taxes.
2. Unemployment Insurance – it’s high for new businesses
3. As your payroll costs go up so does your workers comp insurance. This is unusually high for our field because of the risk of injuries from clients .
4. Payroll software (your accountant may handle this)

How much should you have saved up before you start your agency? Well, that’s hard to say. If you plan on working another job and starting your business at the same time, you may not need that much. This is especially true if you plan to do the BT and BCBA work yourself. However, the important thing to understand is that insurance reimbursements take time and can often be denied for legit/non-legit reasons. You’ll want to try to work with insurance companies that can pay within 30 days (read your contract). If you don’t have ABA billing experience, I highly highly recommend working with someone who is. Many practice management platforms have billing integrated into their systems. They can work with you in getting you set up on how to bill for services or bill services for you.

Here comes the problem. You’re growing and now you have to pay staff on a bi-weekly or semi-monthly schedule. However, you’re not getting paid for another 30-45 days. Here are my tips:

1. Understand your billing VERY well. Even if you are having someone else do it, you need to be able to learn how to do it yourself. I will talk about billing + documentation in another post, but for the purposes of this post, you need to make sure you understand how to get your money. You should always know what your A/R is at all times.
2. You need to have cash reserves for payroll. There is no way around this. You may come across denials, late reimbursements, or other issues. Regardless of why you didn’t get paid, your employees need to get paid. Make sure you leave enough in your bank for a few months of payroll. As providers get larger, I recommend having an emergency credit line.
3. Initially, you should bill as frequently as possible (i.e., daily). There are get practice management softwares out there that allow you to bill as frequently as you want.
4. Keep track of your EOBs (explanations of benefits) and make sure that you got paid what you billed out. If not, understand the reason, correct any mistakes, and re-bill immediately. You’ll then need to wait again (i.e., 30 days) to get your money.
5. Negotiate your rates. In order to have more cash reserves and pay for the current/future overhead, you will want to negotiate your rates with the insurance company. Providers are not allowed to disclose rates, but you should always try to negotiate your rates.
6. Make sure your financially comfortable for a few months just to be safe. Whether that’s your spouse working, a second job, or savings..etc.

There is much more to managing money/billing than what I just posted here, but hopefully this gives you an idea of what you’re in for.

Let’s Get Started

Alright – so you thought about it for a while and you’ve come to the conclusion that owning an agency is right for you. Great! Let’s get you started then!

Now, I am assuming you have determined that you have the clinical experience to run an agency. I’ll be writing about the necessary clinical skills require to run an agency later on, but you probably shouldn’t be running an agency if you just received your BCBA during the last testing period. Even insurance companies are asking for at least 1 year of post BCBA work before getting credentialing. Get some experience and make sure you are confident with the science of ABA.

This is how you get started:

1. Determine your structure. You’ll need to determine whether you will be an independent BCBA doing work on your own (no employees) or starting an agency and employing behavior technicians. Majority of you will be starting an  in-home agency and employing technicians. In order to do that you need a business name. Think of something unique and make sure that no one else has that name in your state. There are other issues with having the same name of another company in a different state, but it’s often rare. I highly suggest consulting with a business lawyer to assist you in making sure your business name is good to use! I would also work with an accountant or an existing business owner to help you determine what corporate structure would be best for you (LLC, S-Corp). Your structure may depend on how many partners you have (if any). You can obtain an EIN number from the IRS once you have figured out the business name and corporate structure. Your EIN is incredibly important and acts like a “social security number” for your business.
2. Address/Phone. The IRS will ask for an address and phone number for your business. I highly recommend that you do not use your home address and personal phone. I would suggest getting a very small space or at least a UPS mailbox (P.O. boxes are typically not allowed) to start off with. Even though you will be working at home, you don’t want your home address published all over the internet. You can get a google voice number for free and download the app on your cell phone.
3. Follow state requirements. Every state has different requirements regarding starting a business. Within the state, each county has different rules as to how to register for your business. You will need to incorporate with your state and get a business license in the county you are operating. A simple google search of “Your state + starting a business” should lead to some answers.
4. Get the necessary insurances. You’ll need liability insurance and workers compensation insurance (depending on the state). You may also need other types of insurances as required by the state.
5. Get an NPI number. You will need an NPI number for yourself and your business. It’s free and can be found through a google search.
6. Logo/Website/Social Media. You’ll want to make sure you have a logo/website ready to go before you begin credentialing. Many insurance companies will take a look at your website. I would suggest working with someone locally to assist you in developing these items.
7. Begin developing processes for your business. The major items include:
   1. Employee handbook
   2. Job descriptions/requirements
   3. Emergency procedures
   4. Reporting structure
   5. Trainings
   6. Data collection (paper or electronic)
   7. HIPAA policies
   8. Practice management software
   9. Billing practices
   10. HR related documents (reviews, disciplinary procedures)
   11. Payroll processes and software
   12. Background checks
   13. Accounting/bookkeeping
   14. Marketing

I haven’t discussed credentialing and working with insurance companies yet. The reason for that is because I suggest you have majority of the groundwork for your business figured out first before getting credentialed. You want to make sure you are well prepared to take on your first client.

The other thing I haven’t discussed is money $$. During this time (including credentialing), it can take some time before revenue starts to come in. Managing money is very important and is what I will be writing about in my next post.

If you are interested in consultation please email me at abapracticesolutions@gmail.com.

I am a new BCBA and I want to start my own company!

So you just got your BCBA? I bet you’re super excited! You got those four letters next to your name and the science of ABA behind you. You’re working at an ABA agency and you think to yourself “Man, I can run an agency way better than these people…I am an all star BCBA…clients will come to me…I’ll show em!”

Eh….just hold up there.

Owning a business isn’t just about being  good clinician. You need to be a good business person. See, the thing with our field vs. other practices is that our practice is composed of many employees. A psychologist may be able to go into private practice and continue what he/she does without much business knowledge (less than ABA) because it’s just only the psychologist providing therapy . However, that’s difficult for a BCBA to do. Many of the programs are based on a two or three tier model where the BCBA is the manager/director of the program. This means you need to hire people to fill a variety of roles. This means more costs, liabilities and headaches. Since a BCBA can’t really live off just one case, you’ll need to have several cases and several employees to have a sustainable business.

Being a good business person requires a special set of skills. You need to be really good with people – which means you have to put away the cold, objective, straight forward face of a BCBA. You also need experience. Not just clinical experience (which you should have several years of), but experience with the administrative side of ABA. The last thing you want is for your business to fail which may cost you money, hurt your clients, and tarnish your reputation.

So what should you do as a new BCBA? Work your way up to an administrative/clinical position first. It’s completely fine to want to start your own practice one day. However, I highly recommend working at an ABA agency as a clinical supervisor and clinical director and learn as much as you can. Particularly ask how you can learn more about the business side (i.e., insurance, HR, hiring, compliance, marketing). Ask your supervisor/higher ups to be your mentor. With that said, it’s always good to be straight up as to why you’re asking to be a mentee. A good ABA agency/BCBA will have no problem with you wanting to start your own agency. There is enough work in this field and we definitely need more qualified agencies.

In the next few posts I’m going to be writing about the different components of running an ABA agency to help new folks get an understanding of how all this works.

How do I become an ABA therapist?

Some of you out there may be interested in the field of applied behavior analysis. It’s a wonderful career choice for people who are genuinely interested in helping people. The work is not easy, but with hard work and persistence, you can make a great career out of something very rewarding. Perhaps you’re a psychology major looking for experience before applying to a PhD program? Pre-Med looking for direct patient care hours? English major who is not sure what they want to do in the future? Regardless of your background – if you love working with children/people, it can be a great job. There is a very high demand for behavior technicians in almost every part of the United States. By becoming a behavior technician you also take the first step in moving towards a solid career path as a Board Certified Behavior Analyst.

What will you be doing as an ABA therapist? Well, that depends on the child and their program. You might be working on teaching the child discrimination skills (matching), requesting items using a communication board, expressively identifying items, or working on having conversations. You might be working on reducing maladaptive behaviors using techniques that have been developed by a BCBA. You might be teaching the child how to wash his/her hands or tie his/her shoe. Do you see where I am getting at? ABA therapy is very individualized. A good rule of thumb to remember is that ABA therapy is used to increase socially significant skills (i.e., washing hands) and reduce maladaptive behaviors (i.e., tantrums). A BCBA will have conducted an assessment and developed a treatment plan prior to a behavior technician providing therapy. The technician will be trained on how to teach skills and reduce behaviors prior to getting started.

So you start your job search on indeed/craigslist, but you’re not sure what to look for. I would typically start my search with “autism therapist” or “autism technician”. You may see ABA therapist, technician, paraprofessional..etc. Don’t let these positions overwhelm you.  These are all entry level positions with different titles. Often times, they require no experience. However, that doesn’t mean you shouldn’t have any experience. The educational requirements can vary depending on the agency. Some agencies only require an HS diploma and others may require a BA/BS degree. I would highly suggest working with kids in some capacity before applying to work as an ABA therapist. You should be comfortable working with children and have a lot of patience. For the purposes of this blog, I will refer to the entry level position as “behavior technician”.

ABA therapy programs are required to be supervised by a Board Certified Behavior Analyst. The BCBA is supposed to make sure the technician is able to implement the programs appropriately and is the main person responsible for that child’s program. The technician is simply implementing what the BCBA has developed for the child (so you need to be really good at following directions).Currently, most insurance companies do not require behavior technicians to be certified.  However, that may soon change….

Many insurance companies are thinking about (some have already started) requiring behavior technicians to be certified. The Behavior Analyst Certification Board (BACB), the same group that certifies BCBAs, has come out with a credential/certification for behavior technicians called the Registered Behavior Technician (RBT). The RBT credential requires a 40 hour training (designed by a a BCBA), a competency assessment administered by a BCBA, and an exam. If you want to set yourself apart, I would highly recommend this credential. I would also look for companies that offer this credential as a part of their training package as it’s highly valuable.

 

I want to start my own ABA business/practice!

So you want to start an ABA business? Great! You’re a new BCBA and your just yearning to start your own practice. Perhaps your tired of how things are ran at your agency and you feel that you can do better? I mean why should your agency get a cut when you can go out and do this on your own?

I agree to some degree.

I started my own ABA practice several years ago. It was one of the best decisions I have ever made in my life. Although I ended up selling my agency (for reasons I will get into later), the experiences I gained were amazing. With that said, I was in the field of ABA for many years before I started my own agency. I made sure I gained enough experience, both clinical and administrative, to make sure I would be successful in my efforts. Even with all of my experiences, I found myself severely underprepared at times.

Here are some quick things to think about:

1. Are you ready to deal with insurance companies? Often times insurance companies don’t reimburse you until 90 days from the date of claim submission. Sometimes, they may even deny your claims because they don’t understand what ABA is (or sometimes they don’t want to pay ) This means that you will have to have enough cash for yourself and the business. Not only will you need cash to live on, but you’ll need cash for payroll and other costs. You will need even more money if you plan to grow and scale your business.
2. Are you clinically prepared? Running your own practice is a huge responsibility. You will be solely responsible for making sure your clients get the highest quality services. Do you have enough clinical experience? Have you defined your scope of practice? What type of training will you be offering your staff?
3. Do you understand all the costs involved? I often hear, “my employer is getting reimbursed $100/hour for my services, but I’m only getting paid $XX,XXX in salary! ” Yes, that might be true. However, your employer is also paying for medical benefits, payroll taxes, liability insurance, workers compensation, laptop, iPads, monthly software management fees, monthly electronic data collection fees, and other overhead costs. Many BCBAs don’t see that the employer is taking all of these costs AND relying on insurance companies who don’t want to pay AND take 90 days to reimburse them. Let that sink in…
4. Do you understand medical billing? You can certainly outsource billing to someone for a percentage or a flat fee (medical billing will be discussed later). However, you still have to understand medical billing and all the rules associated with it. Medical billing can be scary, and the wrong move could mean the end of your business. You need to make sure you’re billing appropriately and have the documentation required by your payer to show proof of services.

This is not a full list of everything you need to know, but a few things that come to my mind. I haven’t even mentioned anything about the ethical/clinical challenges.

I find that many people are very underprepared when they decide to start their own company. I’ve been finding that many more people don’t understand the difficulties that their employer may face on a day to day basis.

By creating this blog hope to provide assistance to people who want to start their own ABA practice one day. I also hope to provide insight, suggestions, and commentary regarding the business side of ABA.