Authorized vs. Rendered Hours: The Hidden Hundreds of Thousands You Are Leaving on the Table
Dan Dube • April 11, 2026
Ask any ABA agency owner what their biggest bottleneck to growth is, and they will almost always say the same thing: " I need more RBTs so I can take more clients off my waitlist."
It makes sense. More clients equal more revenue, right?
Not necessarily. In fact, obsessing over your waitlist is often a distraction from a much more expensive problem hiding in plain sight. You don't necessarily need more clients to boost your cash flow. You need to actually bill for the clients you already have.
Welcome to the Utilization Gap.
The 1,000 vs. 650 Trap
Let’s look at the math. Imagine your agency has 1,000 authorized hours of therapy per week across your active client roster. You fought hard for those authorizations. Your clinical team did the assessments, fought the insurance companies, and won the hours.
But when you look at your actual rendered and billed hours for the week, you only hit 650.
Where did those 350 hours go?
- They vanished into late cancellations.
- They disappeared when an RBT called out and you didn't have a sub-coverage system.
- They evaporated because your BCBAs’ caseloads are poorly balanced, leaving them unable to fulfill their supervisory hours.
If your average blended reimbursement rate is $65 an hour, those 350 unbilled hours just cost your clinic $22,750 this week. Spread that over a year, and you are leaving over $1.1 million on the table—all from clients who are already in your system.
Where the Leaks Happen: The Big Three Codes
To fix the Utilization Gap, you have to stop looking at your schedule as a whole and start tracking your rendered percentages across the three major CPT codes:
- 97153 (Direct Therapy): This is the bulk of your revenue, and it is the most vulnerable to the Utilization Gap. If your 97153 utilization is hovering around 60% or 70%, your scheduling matrix is broken. You need ruthless block scheduling and a strict, enforced cancellation and make-up policy to push this number into the 85%+ range.
- 97155 (Protocol Modification): This is where BCBAs often drop the ball. If a client is authorized for 4 hours of 97155 per week, but the BCBA is only rendering 2 because they are "too busy" putting out administrative fires, your margins are bleeding. You must track BCBA utilization just as aggressively as RBT utilization.
- 97156 (Parent Training):
The forgotten code. Parent training is clinically vital, yet it is consistently the lowest utilized code. If you have authorizations for 97156 that are routinely expiring unused, you are sacrificing high-margin revenue that your BCBAs could be conducting via telehealth.
The Fix: Stop Counting Clients, Start Measuring Utilization
You cannot fix what you do not measure.
To instantly boost your cash flow without spending a dime on marketing or acquiring a single new client, you need to implement a Utilization Worksheet. Every Friday, your leadership team should be looking at exactly what percentage of authorized hours were actually rendered for 97153, 97155, and 97156. The following should be tracked by BCBA caseload:
- Authorized hours for the week (by code)
- Scheduled hours for the week (by code).
Note: a discrepancy between authorized vs. scheduled hours usually means a staffing/hiring issue. - Rendered hours for the week (by code).
Note: a discrepancy between scheduled vs. rendered hours usually means a problem with client and/or staff callouts.
When you track it, you can pinpoint the leaks. When you pinpoint the leaks, you can hold your staff and clients accountable. And when you hold your staff and clients accountable, your cash flow dramatically improves.
Stop Leaving Money on the Table
If you know your agency has a Utilization Gap but you aren't sure how to build the operational systems to fix it, we have two ways to help you right now:
1. The Q2 ABA Business Bootcamp
Join us for our upcoming interactive Q2 Bootcamp in June 2026. We will dive deep into block scheduling, caseload balancing, and the exact capacity matrices you need to push your utilization rates to maximum profitability.
👉
[Click Here to Register for the Q2 Bootcamp]
2. The Grapevine Group Certificate Program
Need ongoing, executive-level support to implement these systems? The Grapevine Group is our premier monthly mastermind and certificate program. You get direct access to our proprietary capacity tools, weekly implementation calls, and a network of high-level ABA founders who are scaling exactly like you.
👉 [Click Here to Apply for the Grapevine Group]
You just had a record-breaking month. Your BCBAs hit their billable targets, your RBTs were fully utilized, and your practice management software shows the highest revenue generation in your clinic’s history. You should be celebrating. Instead, it is Thursday night, and you are staring at your bank account, sweating over tomorrow’s payroll run. You are asking yourself the same question every scaling ABA agency owner asks at some point: "If my Profit & Loss statement says we are making so much money, where is all the cash?" Welcome to The Bank Balance Illusion . If you are running your ABA agency strictly off a traditional P&L, you are flying blind. Here is why your clinic looks profitable on paper while you are constantly fighting for cash—and exactly what you need to do to fix it. The Danger of the Traditional P&L Your accountant loves your Profit & Loss statement. It is a great tool for filing taxes, but it is a terrible tool for running a multi-million-dollar clinical operation. The problem lies in how revenue is recognized. Your P&L records revenue the moment a session is completed and billed. On paper, you earned that money in real-time. But in the real world of ABA insurance billing, that cash doesn't exist yet. You cannot pay your staff with accounts receivable. You cannot pay your facility rent with an "authorized unit." The Payroll Gap This discrepancy creates what we at the ABA Growth Team call the Payroll Gap . Your outflow is rigid. Your RBTs, BCBAs, and administrative staff must be paid every 14 days, like clockwork. Your facility lease is due on the 1st. Your inflow, however, is entirely at the mercy of insurance companies. You are carrying the cost of payroll for 30, 45, or sometimes 60+ days before the insurance payor actually cuts the check. The faster you grow, the more staff you hire, and the wider that Payroll Gap becomes. Growth literally drains your cash reserves. The "Turnaround Multiplier" To close the gap, you have to realize that not all revenue is created equal. If you look at your Master Payor Matrix, you will see that different insurance companies have wildly different reimbursement timelines. Payor A might have a clean 14-day turnaround, while Payor B routinely takes 45 days and requires constant follow-up. If your caseload is heavily weighted toward Payor B, your cash flow will always be choked, regardless of how high your billing rates are. You need to assign a Turnaround Multiplier to each payor to accurately predict when that billed revenue will actually hit your checking account, and then ruthlessly balance your BCBAs' caseloads to ensure a steady mix of fast-paying and slow-paying clients. The Solution: Stop Looking Backward A P&L tells you what happened last month. To survive and scale, you need to know what is going to happen next month. You need to implement a 13-Week Cash Flow Predictor . This is an operational model that maps your exact cash position 13 weeks into the future. It factors in your current cash on hand, your specific payor Turnaround Multipliers, your aging AR, and your upcoming payroll runs. When built correctly, it acts as an early warning system. It tells you in Week 2 that you are going to have a cash shortfall in Week 8—giving you six full weeks to escalate AR collections, secure a line of credit, or adjust schedules. No more Friday morning panic. No more Bank Balance Illusion. Just predictable, executive-level control over your money. Ready to Fix Your Cash Flow? Reading about the Payroll Gap is one thing; fixing it is another. If you are a scaling ABA agency owner, you cannot afford to guess your cash flow. You need the tools to build your 13-Week Cash Flow Predictor so you can finally step out of the daily fires. We have two ways to help you build this right now: 1. The Q2 ABA Business Bootcamp Join us for our upcoming interactive Q2 Bootcamp. We will tear down the traditional P&L, expose your margin leaks, and teach you the exact financial and operational mechanics needed to run a highly profitable clinic without burning out. 👉 [ Click Here to Register for the Q2 Bootcamp ] 2. The Grapevine Group Certificate Program Need ongoing, executive-level support? The Grapevine Group is our premier monthly mastermind and certificate program. You get direct access to our proprietary financial tools, weekly implementation calls, and a network of high-level ABA founders who are scaling exactly like you. 👉 [ Click Here to Apply for the Grapevine Group ]
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So many practice management systems out there...some have been around for over a decade, and it seems that new ones pop up every few months. How can you choose the best system for your practice? See my tips below. I’m fortunate to have a rather unique background when it comes to evaluating practice management systems. I am a former co-founder and CEO of both a cloud software company and an ABA business. In the last 10 years, I have reviewed just about every practice management system out there, and have negotiated contracts with several of them. Based on that experience, here are 6 factors that I think are crucial if you are considering investing in a practice management system for your company. (Please note: I will not make any specific software recommendations here, because each solution has their own strengths and weaknesses, and every client’s set of requirements is unique.) #1: The system must NEVER go down! Practice management is a “mission-critical” application. In most cases, you will have BTs taking data on tablets, and both clinical and operational management will need constant access to the system in order to do their jobs. Make sure that your contract ensures that the system will have an “uptime” of at LEAST 99.5% (the bare minimum for any cloud software application). Last year, a major practice management software company made headlines when their system crashed several times a day. My employer at the time was affected by these outages, and it caused severe issues internally at the company. I have a strong preference for systems that are built on enterprise platforms with large user bases that have been proven to never go down. For example, there are a few practice management systems out there that are built on top of the Salesforce platform, which has proven performance at a large scale of users globally. (Systems that run on Salesforce include Artemis ABA, Lumary, and TotalTherapy.) #2: “All in one” is not always better. My doctor once told me that “multi-symptom” cold medications that contain ingredients to fight different symptoms do an “okay” job at managing the symptoms, but not as good a job as the individual medications for each symptom. This analogy can apply to practice management systems. In some cases, a large system that “does it all” really only does an adequate job at each task, whereas some focused systems (like data collection) do a really great job at that task. You will need to evaluate your priorities when looking at solutions. (There are some packages out there that “do it all” really well.) #3: Pricing models Most of the pricing models I’ve seen fall into one of 3 categories: 1) user-based licenses with unlimited clients (the number of your staff using the system), 2) client-based licenses with unlimited users (one license for each client you are supporting), or 3) a hybrid model, where you pay for each internal user, with a surcharge for each client. In my opinion, the most cost-effective of these options is the user-based pricing model , because hopefully your practice will have more clients than staff. In an ideal scenario, the software provider should provide a different price for “clinical users” than for “admin users” (which should be cheaper, since they won’t use all of the clinical features). #4: Be cautious of features like “labels”, which are prone to human error. This is a little “techie”, but it is very important. As I mentioned, a previous employer used a large practice management system, and heavily used a feature called “labels” to classify and make associations (for example, which region an employee worked at, which clients were served by a specific BCBA, etc.). On the surface, this is a very useful feature for querying the system and getting quick results. The problem is that you are dependent on your users to: 1) remember to apply a label every time, and 2) apply the CORRECT label every time. This is ripe for human error. I saw many reports with incorrect financial tracking information because labels were applied incorrectly, and there was no way to validate it. This defeats the entire purpose of a practice management system. This is another reason that I like systems based on a Salesforce platform, which is a true database. You can make data entry fields be “required”, and then provide a drop-down list of values. This helps to ensure that users must enter the data and largely takes away the ability for a user to enter an incorrect data value. Your reporting is much more trustworthy in a system like this. #5: Read the ENTIRE contract. In one instance where I was negotiating a contract with a large practice management vendor, I noticed that when I printed their standard contract it was only a few pages long. However, there were lots of links in that document. I’m guessing that most ABA business owners only read the 2-3 pages and then sign. I clicked on every hyperlink and printed out each linked document, and the total contract was approximately 100 pages long! It had lots of uncomfortable things hidden in the linked documents, such as automatic contract renewals with a baked-in price increase and an automatic increase in licenses each renewal period. Make sure you always know the fine print in any contract that you are signing! #6: Contracts are ALWAYS negotiable. I’m not a lawyer. (That would be my brother.) But, I do know enough about the law to be aware that a contract is a legally binding document between 2 parties. Both parties have the ability to negotiate the terms. If you don’t like the terms in a standard contract from a practice management software company, tell them what you want changed. You will almost always either get what you want or reach a fair compromise.
I get asked frequently about tips for negotiating (or renegotiating) ABA reimbursement rate contracts with insurance payors. This is something that I had to learn the hard way when my wife and I started our ABA company a decade ago. Like many other providers, we made some of the classic “rookie mistakes”: we took the “standard” rates that commercial insurance payors offered without questioning them, we accepted their slowness in paying our submitted claims, and we survived a multitude of ridiculous claim denials…all while we were in the process of “proving” ourselves to be worthy providers in their network. After a couple of years of dealing with this, I had reached the breaking point. Our cash flow was continually in crisis, due to low rates and slow reimbursement cycles. It was time to renegotiate with our payors. But this time around, I was ready and armed with these 2 sets of facts: Minimum acceptable rates Adequate provider network Factor #1: Minimum Acceptable Rates How do you know if a rate offered by a payor is a “good” rate for your business model? You need to understand your costs! You need to be able to answer this question: What is your “ loaded hourly rate ”? Calculate Your Costs A loaded hourly rate gives you an estimate of the rate that you need to charge to cover all of your costs, in order to break even. The loaded rate is calculated as follows: Loaded Hourly Rate = All Monthly costs / Total monthly billable hours Let’s break this down to make it more understandable: All monthly costs Over a sample period of time (6-12 months), calculate your company’s average costs per month. This number should include all payroll costs (for both billable and non-billable employees), and all overhead costs (rent, insurance, software fees, marketing, etc.). For our example, let’s say the average total monthly cost is $100,000. Total monthly billable hours: Use the same sample period of time (6-12 months) to determine the number of billable hours each month. If you have a practice management system, you should be able to pull a report or query that summarizes this information for you. This will include hours for all billable codes for RBT/BT therapy sessions, as well as BCBA billable hours for supervision and parent training. If you have other sources of revenue besides insurance billing, include those hours as well. Take an average number of these monthly billable hours over the sample period. For our example, let’s say that our average number of billable hours each month is 2,500. When you have determined these numbers, use the formula to calculate your loaded hourly rate. For example: $100,000 (average monthly cost) / 2,500 (average monthly billable hours) = $40/hour (loaded rate) You have just determined that you need to make at least $40/hour just to break even. In this example, if your current insurance contract with a payor is paying you less than $40/hour, then you are losing money on every hour that you bill to that payor! Add Your Profit Margin! Once you have determined your loaded rate to get a baseline number to cover your expenses, you need to add in a profit margin. I recommend calculating 3 scenarios: a minimum acceptable rate , a reasonable rate , and a wish rate . To continue my example, I will calculate 3 rate proposals: a 15% profit margin (acceptable rate), a 20% profit margin (reasonable rate), and a 25% profit margin (wish rate). If our baseline loaded rate is $40/hour, then our 3 scenarios look like this: Minimum acceptable rate: $46/hour (15% profit margin) Reasonable rate: $48/hour (20% profit margin) Wish rate: $50/hour (25% profit margin) Start your negotiation by asking for your wish rate. But, do not accept anything less than your “minimum acceptable” rate. If they refuse to meet even your lowest acceptable rate, it’s time to walk away and focus your energy on revenue streams that will be healthier for your business. We left the Cigna network in New Hampshire in 2019 because their “best” rate was below our loaded rate costs…and they were unwilling to negotiate, even though we were one of the largest providers in the state! Speaking of which… Factor #2: Adequate Provider Network This one is a little bit more abstract, and is highly dependent on the number of “in network” ABA providers in your region for a particular payor. Essentially, insurance providers are supposed to offer an “adequate provider network” for their subscribers. (For Medicaid, this is a requirement under federal law.) Many payors will claim (sometimes truthfully) that you are welcome to choose to leave their network, as they have many other providers in their network that can take the cases. But, if you do your homework, you can sometimes counter this argument (depending on the market factors in your region): Talk to parents who reach out for you to inquire about services. Ask them if they have been calling other providers. In many cases, they will tell you that everyone else has a long waitlist. If you have a friendly relationship with other providers in your region, reach out to them and inquire about their waitlist for a particular payor in the event that you may want to refer some prospective clients to them. They will also likely admit that they are maintaining a waitlist. You can use these facts to inform the payor that they are failing to offer an adequate provider network, as you have researched with parents and other providers and everyone is carrying a long waitlist. This is putting an “unnecessary administrative burden” on their subscribers, and it is causing a “ unnecessary delay in timely access to medically necessary services ”. (These specific phrases can be a trigger for insurance companies.) If you are able to accept new clients with little to no wait, inform the payor of this and emphasize that this will add value to the adequacy of their provider network. It won’t always work, but it is another weapon in your negotiation arsenal that can come in handy. Conclusion Working with insurance payors is one of the biggest challenges an ABA provider will have to deal with. It is often a “David and Goliath” situation, where you as a small company have to attempt to negotiate with a large, faceless corporation. But, never forget that a contract is between 2 parties, each of whom have equal rights to negotiate. Arm yourself with facts and know what you want to accomplish before entering into the negotiations. And, if the other side is not willing to reasonably accommodate and compromise fairly, don’t be afraid to walk away. If enough ABA providers start doing this, the lack of an adequate provider network will bring payors back to the negotiating table. Learn more from our 2-CEU Course! Using KPIs to Renegotiate Insurance Contracts This 2-CEU course provides information on how to set up and monitor Key Performance Indicators (KPIs), and how to use KPI data as evidence of quality to renegotiate rates from insurance payors. Price: $79 Purchase now
