Managed Care Contracting Advisory and Negotiation Support

InBloom provides high-quality, comprehensive Applied Behavior Analysis (ABA) therapy services to children diagnosed with Autism Spectrum Disorder (ASD). It is a rapidly growing organization that employs over 450 registered behavior technicians and board-certified behavior analysts, and operates in eight states (Florida, Wisconsin, Massachusetts, Texas, Colorado, Arizona, Connecticut, and New Hampshire).

ABA therapy is the gold standard treatment for ASD. It is proven to be effective for building the child’s adaptive skills, reducing maladaptive behaviors, enhancing independent functioning, and preventing the deterioration of skills and regression. Historically, ABA therapy services have not been reimbursed, but efforts in the early 2000s increased national coverage from both state and private funding sources.

Despite ABA coverage expansion (and the increased demand for ABA services), InBloom was operating under a mixed managed care contracting model; it was in network with some payers but out of network with others. As InBloom continued to grow its national geographic presence and open new locations, it needed to secure in-network agreements with the major commercial payers in each market, and, in particular, competitive reimbursements that cover the costs of high-quality ABA services. Without a dedicated managed care department, InBloom was hampered in its efforts to initiate and manage concurrent payer negotiations across multiple states.

ECG was engaged by InBloom to provide ongoing analytical and advisory support and to lead negotiations with each payer as InBloom initiated the contracting process across all markets.

Activities were focused around four key elements:

• Value Proposition: ECG developed a meaningful value proposition for contract negotiations that was based on an assessment of InBloom’s competitive market position, care delivery strengths, and proven clinical outcomes.
• Credentialing: To reduce the time spent on establishing an in-network agreement, ECG worked with InBloom to expedite the credentialing process by proactively identifying provider representatives, ensuring the correct application forms were used, confirming application submission processes in advance, and following up biweekly to check on credentialing status.
• Contract Language: To protect InBloom against future negative financial impact, ECG reviewed all the contracts for timely filing language and other key contract provisions. Payer Representative Identification and Rate Negotiations: In order to attain commercial reimbursement that covers the costs of providing high-quality ABA services, ECG identified appropriate payer representatives and led negotiations across several states.

InBloom secured in-network agreements with major payers in eight states, including several national agreements. Specifically, InBloom has:

• Established relationships with dedicated provider representatives with major payers in each of the eight markets.
• Executed agreements that can be amended to add new locations and providers as InBloom continues to grow nationally.
• Ensured that telehealth services (e.g., BCBA supervision and family training services) are included in contracts, where permissible.
• Achieved rate premiums over the base fee schedule on select agreements.

Additionally, InBloom is now equipped to maintain its managed care contracts internally.