I said what I said. If you have chosen to work for insurance companies as a BCBA, you are inherently unethical. Show your work, you say? Happily. Alright kids, everyone take out your BACB Code of Ethics, and open up to the Core Principles.
Let’s Start at the Beginning
Before the Code of Ethics gets to the actual Codes, there are the Core Principles. Any principles are going to be subjective by nature, but subjective doesn’t always mean a strong argument can’t be made in one direction or another. The first principle contains several well defined examples:
Let’s start with the first bullet point: Protecting the welfare and rights of clients above all others. This immediately reminded me of Van Houten et al. (1988): The Right to Effective Treatment. Whether you want to admit it or not, part of your job working at an insurance company is to do whatever it takes to minimize what insurance has to pay out. If that wasn’t the case, we wouldn’t have to waste hours per learner describing and justifying our clinical decisions. Insurance companies like to excuse this by claiming they are just trying to ensure practitioners are considering everything when making such clinical decisions.
OK but that’s literally our job. If we are assuming that clinicians aren’t doing such due diligence for their learners, how is another BCBA who has had zero contact or direct observations with that learner going to do any better?
Jump down to “actively identifying potential and active and actual conflicts of interest and working to resolve them in a manner that avoids or minimizes harm.” As a BCBA employed by the insurance company, this principle creates a direct conflict of interest. I have had many an exchange with insurance BCBAs, and not one of them has disclosed such a conflict of interest. As noted above, part of one’s job at an insurance company is invariably to minimize the amount of money the insurance has to pay out. As such, the contingencies in place reinforce behaviors that deny coverage and risk punishing behaviors that provide “too much.” Just below that, we have “actively identifying and addressing factors that might lead to conflicts of interest, misuse of their position, or negative impacts on their professional activities.” So by accepting such a position, you have directly violated this core principle.
Now let’s go to the last one: “Effectively and respectfully collaborating with others in the best interest of those with whom they work and always placing clients first.” First, let’s reiterate one thing: No one with common sense actually believes that these companies are wanting to make sure clinicians are providing appropriate quality of care. These reviews and questions are simply in hopes of coming up with a reason to avoid paying as much as possible (see also Ethics Code 1.10). Challenging case managers on their clinical decisions based on proper direct observation is not collaboration. Making clinicians waste time explaining themselves and justifying their decisions to some rando on the phone who’s never laid eyes on the learner in question is not in anyone’s best interest but the payor’s. The time spent filling out forms, waiting on hold, and going through the motions of these conversations also takes time away from the learners this process is supposedly “benefitting.”
And Now: The Ethics Codes
Every now and then, a BCBA finds themself working with a learner who has a diagnosis other than autism. Usually it’s in addition to, because insurance in most if not all US states won’t cover ABA without an autism diagnosis – another absurdity that I have not seen challenged by insurance BCBAs. Somehow a diagnosis of Down Syndrome or Kleinfelter or TBI never seems to change the requirements or conversations about the goals for these learners. If anything, there is more pushback about whether ABA should be included in their treatment. Insurance companies actively push the idea that ABA is an Autism Therapy™, and I have personally experienced conversations implying that these additional diagnoses would somehow render ABA ineffective.
These arguments are not only obvious reaches, but they also convey a disturbing lack of understanding for ABA as well as how people can be affected by these different conditions. When an insurance company decides to to make a clinician go through a “peer” review, the reviewer never mentions their experience or expertise with these different populations. Making clinical decisions about a learner from a population with which you are unfamiliar is practicing outside of your scope.
The “Peers” in your Review
Just pulling from personal experience here, but I feel it’s important to discuss what types of BCBAs are showing up in these positions. Social media, while often an echo chamber, can still serve as data from a hefty sampling of a community. It’s raised awareness to various issues and brought about societal change – for better or for worse. One of the most common discussions seen in practitioner spaces is burnout.
Across every forum where BCBAs hang out, from Facebook to Reddit and beyond, there are inevitably conversations of being burned out, wanting to leave the field, what other opportunities there might be for BCBAs who are tired of managing cases for therapy with Autistic learners. Peppered in these conversations is where you see comments about choosing to work for insurance companies.
Consider this a hypothesis based on informal pilot data: The BCBA reviewing the learner’s treatment plan has a high probability of being someone who burned out, lost their passion for the field, and now just needs a 9-5 to provide a steady salary without having to go back to school and get a whole other degree.
This is not a judgment on being burned out. I have personally experienced it, and there is no personal fault in feeling like you need to step back or even leave completely. What I am judging is the decision to work for insurance companies in response to those feelings.
To be fair, I don’t think most BCBAs go to work for insurance companies with malicious intent. As stated above, caregiving fields in general can wear a person down (though insurance undoubtedly adds to that weight). But BCBAs are still humans, and it’s a well-known fact that the specific human looking over your treatment plan and what mood they happen to be in that day can and does affect whether or not your recommendations are approved or not. This human tendency to take our misery out on others is why punishment procedures and power dynamics are a dangerous combination.
Working at an insurance company though means you literally control whether or not these learners receive services. That is power. Making decisions counter to those made by the treating clinician, especially when that benefits the insurance company’s profit margin over the learner’s needs, is abuse of power. I’ve said it before and I’ll say it again: Some rando at an insurance company who has never laid eyes on the learner has nothing to offer that learner over their treatment team.
Call me cynical, but I have never talked to anyone at an insurance company who has been anything other than disingenuous about their intentions. If these processes had anything to do with actual quality of care, there wouldn’t be a constant risk of families losing services if the person on the phone isn’t having it that day.
Critical information that’s never disclosed:
- What happens to you if you don’t approve the hours?
- What happens to you if you do approve the hours even though all of your boxes aren’t checked?
- How do you decide when the recommended number of hours is or isn’t appropriate without directly observing the learner in question? (we’ll come back to this)
- How do you benefit, if at all, by approving or not approving hours?
- What contingencies are in place if you do disclose this information versus if you don’t?
I know this is probably not what the BACB meant when they wrote this code, but that doesn’t mean these questions aren’t still relevant. Given the power insurance holds over services for learners, it’s also fair to consider this information critical.
Collaboration across providers and caregivers is necessary and invaluable. Yet, insurance companies consistently throw barriers into this by refusing to pay for services outside of clinics (sometimes even including homes), refusing to pay for meetings and collaboration with schools, etc., and refusing to pay if another professional is present, such as a speech or occupational therapist. As a BCBA, by choosing to work at places that support this, you are endorsing and even justifying these barriers. By endorsing these barriers, you are violating this code.
Insurance companies have been keeping an ever-shrinking list of assessments and tools they find acceptable to justify medical necessity. These lists usually reject evidence-based assessments such as PEAK and Essentials for Living. While every assessment absolutely has its flaws, they are the tools that we have, and the reasons given for rejecting these tools are often nonsensical. Without evidence-based justification for disallowing these tools over others, it can only be assumed that these decisions are simply to throw barriers between practitioners and their learners’ right to effective treatment.
To further demonstrate this point, I’d like to share some personal experience. I once had a treatment plan go to “peer” review because the insurance company decided they didn’t like that I was requesting hours for an 11 year-old. Data demonstrated steady progress over the last six months, and PEAK showed that many skills had been gained, but there were still areas of need. The review went like most: The BCBA-D would ask a question, then interrupt me within 3-5 words to tell me why I was wrong, then went on a tirade in which they made the following points:
- PEAK was not an appropriate tool. The only acceptable tools were the ABLLS-R or the VB-MAPP, but that those weren’t appropriate for the learner in question because of their age (not developmental level, though that part was true too). They were unable to come up with an example of an “acceptable” assessment tool for that learner.
- BCBAs are not able to work on language or social skills. Those are outside of our scope and should be left to the 15-30 min per week of speech most learners get through public schools.
- BCBAs are not to work on daily living skills. Those are also outside of our scope.
- When questioned as to what exactly this BCBA-D thought our scope was since daily living skills, social skills, and language were off the list, the answer was challenging behaviors and stimming. The only thing BCBAs are qualified to work on is reducing behaviors, according to Dr. Insurance, BCBA-D (no, I will not name names, I’m not a total idiot).
- If the learner is appropriate for group treatment (i.e. 2+ learners to 1 RBT), then ABA is already irrelevant and it’s time to look at discharging.
- If the learner does not engage in any dangerous behaviors, then ABA is already irrelevant and it’s time to look at discharging.
- After this enlightening conversation, the BCBA-D agreed to approve the hours out of the goodness of their heart or something, but literally promised to reject them at the next 6-month re-authorization.
Thankfully, the learner was able to make enough progress to appropriately reduce hours by then and thus, avoid having services cut off completely.
Aside from the disturbing lack of understanding for their own field and training, there also seemed to be a disturbing lack of understanding for assessments as a whole, what assessments have appeared since 2008, and how these assessments are used. The amount of ego in that conversation also provided plenty of evidence for abuse of power, again throwing unnecessary barriers between a learner and their ability to access effective treatment.
On that note…
Ask any provider what the biggest barriers to providing services are. I want to see the data on the ones who don’t mention insurance. Hell, I want to see the data on the ones who don’t put insurance within the top 5 biggest interferences with service delivery. By working for the insurance companies, BCBAs contribute to and endorse those barriers. Endorsing these barriers violates Ethics Code 3.01:
The amount of wasted time takes away from BCBAs’ ability to maximize benefits for their learners. The risk of having to reduce hours or lose coverage altogether causes harm for both the learner and their families. Once again, this is usually where the other side will argue that they just want to make sure clinicians are making appropriate and high quality clinical decisions. Well, here are some examples that have been given for denying the recommended number of hours or denying services altogether, just from my own personal experience as a practitioner from 2008-2024:
- The diagnostic report is more than 3 years-old (because you never know, the autism might magically go away).
- Verbatim from a rejection letter that is burned into my brain forever: “Client is male.”
- Calling into question the validity of a diagnosis for a learner who is nonverbal and displays all of the classic signs of what insurance likes to call “Level 3 Autism.” No, no one from the insurance company ever directly observed the learner. They just decided the learner wasn’t really autistic, denied coverage, and cut that poor child and their family off from services.
- Learner turned 7. Time to stop ABA and let school handle everything (paraphrasing but not much).
- After looking over some graphs, deciding that the learner could always perform the targeted skill, they just didn’t want to. Instead of approving hours, the recommendation was “family counseling” for some reason. I didn’t get the reason, because they hung up on me before I could ask.
- Behavior analysts don’t work on independent living skills, language acquisition, academics, social skills. Those are the jobs of school/speech therapists/social workers. We can only work on challenging behaviors and reducing stimming.
- “The goals don’t address the ‘core deficits of autism'” – i.e. we didn’t use language that was pathologizing enough.
- Behaviors of note had increased recently, therefore “aba isn’t working.” Instead of taking a scientific approach to determine why the behavior was increasing and implementing something more effective, the recommendation was to just abruptly stop services and have the family “try something else.”
I’m open to thoughts on how any of these maximized benefits for the learners.
But we should fight.
Unfortunately, Ethics Code 3.12 requires us to engage these arguments. Even more unfortunate though is the pattern among ABA companies in which directors are encouraging practitioners to skip this one in favor of reinforcing insurance behavior by giving them exactly what they demand regardless of how that might affect the learner. I have personally experienced companies trying to force BCBAs to tailor their treatment plans, recommendations, and goals to insurance companies’ demands and preferences. Just a little reminder: These demands and preferences often exclude evidence-based practices and tools.
BCBAs working for insurance companies are contributing to and by proxy endorsing actively throwing barriers between learners and appropriate services. These barriers then force more ethical BCBAs to do more advocating than should be necessary with varying levels of success.
Lastly, 3.14-3.16 have to do with what to do when it’s actually time to fade services.
For any unethical BCBAs out there who may have forgotten, appropriate transition usually includes fading supports, ensuring maintenance and generalization over time and across people and environments, and systematically reducing hours until the learner is eventually discharged from ABA services.
I can count on one hand the number of learners I’ve been able to transition that way.
Most of the time, services are ended because insurance interrupted services, either by refusing to cover it at all or covering so little or with such a high copay that families are unable to afford services even with insurance coverage. Other interruptions have included: The family being unable to obtain an insurance plan that covers ABA, the family being unable to obtain a plan from a company that the service provider takes or is in network with. Occasionally, families will move or simply decide to discontinue services, especially when prioritizing school over services.
And as a BCBA working for insurance companies, everything you do contributes to that, and strengthens the argument from insurance that these actions are valid or acceptable.
To be fair, ABA companies could probably be more transparent on why they don’t take certain insurances or aren’t in-network. Insurance companies constantly cut rates and cut the amount of hours they will allow. At one time, I worked in a state in which Medicaid told their members that they covered ABA, when in reality they only covered for a BCBA to provide direct services up to no more than a few hours a month (I can’t remember the exact number but it was less than 10). Getting clinicians credentialed with insurance companies also takes an absurdly long time and is connected to the individual company, not the practitioner themself. So it has to be redone at every company that practitioner works for. Insurance also attempts to dictate how much providers can charge people who are receiving services without going through insurance. None of this bureaucratic bullshit is the provider’s fault, but the provider is the messenger who inevitably is going to get shot.
If providers were more transparent about this, it would prevent insurance companies from making them look like the bad guy. It would also shed some light about why our medical, psychological, and behavioral care seems to be decreasing in quality lately. Then people can bitch about it on social media, and well, we know where that can lead.
Conclusions
A friend and colleague of mine once relayed a question to an ABA ethicist. The question was about whether any entity outside of the treating clinician themself could alter or impose requirements on recommended hours or goals. The response could best be summed up by their final line:
“No, I make the clinical decisions here.”
It should be common sense that clinical decisions made in the best interest of any learner should be made by the one directly observing and interacting with them. Basic practice 101 is that clinical decisions are not made without direct observation. Sure, indirect methods such as reading graphs, caregiver interviews, and functional assessments serve a great deal in fueling decision-making, but no one who has managed to pass the exam should think that these methods alone are sufficient. Technically, BCBAs reviewing treatment plans aren’t even doing half of that. Functional assessments and caregiver interviews are being delivered to them second-hand by a clinician, not by the caregivers or staff themselves.
Look, I’d be lying if I said I didn’t have moments where I was sick of it. Burnout is a whole other topic and a growing, persistent issue in this field. The draw of a simple, 9-5 office job with a decent salary where you can kind of use your education is an understandable one. But to give any benefit of the doubt to the intentions of an insurance company hiring a BCBA is naive if not intellectually dishonest. I don’t have a good suggestion for what to do when you’re burned out of the field and can’t go back to school and start all over. Perhaps the insurance gig works for you, but then you might as well let your certification lapse. By maintaining that credential you are agreeing to practice within the Code of Ethics, and that simply isn’t possible with that kind of career choice.
Though I can’t help but wonder about anyone who chooses a job in which the goal is to profit off of vulnerable people and their families while throwing one barrier after another into their access to necessary treatment, whether that be medical, psychological, or behavioral. If you can sleep at night and do that as a career, then you’re probably not someone I want to know.