The Truth About BCBA Credentialing and Billing

Hello readers,

There is a lot of confusion and a general lack of concrete information about payor requirements with respect to credentialing BCBAs. Questions we’re often asked: Does every BCBA need to be credentialed? Can a new hire BCBA provide supervision and conduct assessments under a supervising BCBA until they are credentialed? If the BCBA worked for another company, do I need to credential them with my company? These may sound like easy questions and ones that should be easy to answer but I welcome you to go on Reddit or the Facebook forums and you will see endless banter from, “yes”, to “no” to the words we all fear – “that’s fraud…”

The truth is that payor policies vary significantly, which is exactly why there’s so much confusion. Some insurers require every BCBA to be individually credentialed with their specific company, while others allow BCBAs to work under a group credential. And just to make it more complicated, these requirements can change without notice. Years ago, when the state mandates first rolled out, it was not uncommon for a BCBA owner to be the NPI provider on all claims. But, it was also the case that that BCBA owner was the supervisor for all of the clients’ receiving services. They conducted the assessments, provided supervision, wrote the session notes and treatment plans. Now a days, more and more companies have owners that aren’t BCBAs and if the owner is a BCBA, they are typically not the BCBA actually seeing clients and supervising them.

Let me try to clear up a few things:

1. Most major payors (Aetna, Cigna, UHC, BCBS) DO require individual credentialing for each BCBA providing billable services. This means your new hire typically cannot bill under another provider while “waiting” to be credentialed. In most cases they can provide 97153 with the exception being Tricare and some state Medicaid’s and MCO’s that require RBTs be credentialed as well.
2. The “incident to” billing also known as Supervisory Billing that works in other healthcare fields often doesn’t apply the same way in ABA. Incident to billing is when, for example, the licensed psychologist or other licensed mental health provider serves as the supervisor of the limited licensees (i.e., those acquiring their hours for licensure). The limited licensees provide the services, but the claim is submitted under the licensed provider’s credentials. In ABA, a non-credentialed BCBA providing supervision that gets billed under a credentialed BCBA is a red flag for most insurers.
3. Yes, if a BCBA worked for another company and is now working for you, they generally need to be credentialed with your company. Provider credentials are typically tied to the Tax ID they’re billing under.
4. 97155 requires the client be present. Therefore, the supervisor is the person who is providing 97155 with the client present, writing the session notes and is the person whose NPI number is on the claim. To be the NPI provider on the claim, they must be credentialed.

Relatedly, Optum just released information about supervisory billing allowances and explicitly stated it does not apply to ABA. Click here to read Optum’s Billing Reference Guide.

What’s the risk of ignoring these requirements? Well, beyond the dreaded “F” word (fraud), payors can and do regularly conduct audits. When they discover services being provided by non-credentialed providers, they can demand recoupment of ALL paid claims – sometimes going back years. I’ve seen practices nearly bankrupted by these recoupment demands.

My advice? Credential all of your BCBAs!

If you opt not to, document everything. Get clear, written answers from your payors about their specific credentialing requirements. Keep these communications in your files. When in doubt, don’t bill for services until you have confirmation.

And remember – just because “everyone is doing it” doesn’t make it compliant. Your practice deserves better than Reddit-level advice on something this important.

Wishing you compliance and peace of mind.

Warm regards,
Kim Finger, Ph.D.
CEO