Communicating Client Expectations: ABA Therapy is a Medical Service, Not a Daycare
Dan Dube • June 19, 2025
Reframe Your Client's Expectations to Improve Outcomes
As ABA business owners, we're dedicated to providing high-quality, effective therapy to children with autism. A significant part of that commitment involves setting clear expectations with our client families. One of the most crucial points to emphasize, right from the start, is that ABA therapy is a medical service, not a daycare.
This isn't just about managing schedules; it's about safeguarding the integrity of the therapy, ensuring positive client outcomes, and fulfilling our responsibilities as healthcare providers to both families and insurance companies.
Why Punctuality and Adherence to Hours Are Non-Negotiable
When a child begins ABA therapy, a personalized treatment plan is developed, based on their unique needs and medical necessity. This plan outlines a specific, prescribed number of therapy hours per week. These hours are meticulously designed to help the child achieve critical developmental and behavioral goals.
- Dedicated, Paid Staff
For every therapy session, we have skilled and paid staff members specifically allocated to that client. When families consistently arrive late or cancel without adequate notice, valuable therapy time is lost. This isn't just an inconvenience; it directly impacts our operational efficiency and the effectiveness of the service we're contracted to provide. - Meeting Medical Necessity Guidelines
Client treatment plans are approved based on medical necessity guidelines. The prescribed hours are not arbitrary; they are deemed essential for achieving the desired clinical outcomes. Consistently missing or cutting short sessions due to lateness makes it incredibly difficult to meet these crucial hour requirements, which can have downstream effects on authorization renewals. - Our Obligations to Families and Payers
As a medical service provider, we have a significant obligation to both our client families and their insurance companies. Our primary goal is to help children achieve the outcomes outlined in their approved treatment plans. Insurance companies authorize a specific number of hours because they are medically necessary. Failure to consistently deliver these authorized hours not only hinders the child's progress but can also impact future authorizations and our relationship with payers.
The Direct Link Between Adherence and Outcomes
It's vital to help families understand that every therapy hour is a building block in their child's development. Just as consistent effort is required to master any skill, consistent attendance and full engagement in ABA therapy are paramount for progress.
Failure to meet the prescribed weekly hours will directly result in not achieving the desired outcomes. We've all seen how inconsistent attendance can slow progress, impede skill generalization, and prolong the time it takes to address challenging behaviors. This can lead to frustration for families and, most importantly, for the child who deserves every opportunity to thrive.
Partnering for Success: Educating and Empowering Families
Our role extends beyond providing therapy; it includes educating and empowering families to be active participants in their child's treatment journey. By clearly communicating that ABA therapy is a medical service, with all the responsibilities and expectations that come with it, we set the stage for a more successful and impactful therapeutic experience.
Success tip: Some of our most successful clients describe make-up policies in their client handbooks. We encourage our clients to have these discussions with clients right from the first intake call, and ensure that they sign off on policies in a client handbook during the kickoff meeting when treatment begins. We encourage a policy that promotes that any missed time is made up within 30 days to ensure that the client stays on track to achieve treatment goals. In some cases, this might mean adding time to the next several appointments. In other cases, clinic-based providers offer make-up blocks on Saturdays. Find the plan that works best for your company.
Let's equip our teams with the language and confidence to explain these critical expectations upfront, ensuring that every family understands the value of consistency and punctuality in achieving the best possible outcomes for their child.
Reduce anxiety, optimize utilization, and increase profitability!
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
