The First 90 Days of an ABA Practice

You just registered your NPI. Congratulations, and I mean that sincerely, because I remember exactly how that felt.

I'm Stephanie Emmons. I'm a BCBA and I own an ABA clinic. I opened it myself, made most of the mistakes available to me, and learned the rest from people who were kind enough to tell me the truth.

This is what I wish someone had handed me on day one. There's no pitch in it. If it's useful, keep it. If you get stuck on something in here, call me and I'll talk it through with you.

Part one

The actual order of operations

Not the tidy version. This is the order I'd give a friend.

1. Sort your entity and your credentials

   • Check whether your state requires a licensed professional in the ownership team. If it does, you either are one or you need to find one before anything else happens.
   • Create your LLC. Create a DBA if you need one. Choose the right entity type for your situation.
   • Apply for your Tax ID, then your NPI. Open a business bank account and get a credit card.

2. Get an address before you need one

   • Have a location in mind or start looking. Insurance and credentialing both need an address to work from, so this blocks more than you'd think.
   • Purchase liability and malpractice insurance.

3. Start the insurance clock

   • Confirm your CAQH profile is current.
   • Start contracting with payers. Then start credentialing once you have a contract. These are two different things and they happen in that order.
   • This is the longest part of the whole process. Start it earlier than feels necessary.

4. Build the practice while you wait

   • Start looking for your lead clinician. Start looking at practice management systems.
   • Finalize your space. Lease, build out, furniture, equipment.
   • Write your policies, handbooks and templates, and have an employment attorney in your state review them.
   • Start marketing locally for both staff and families.

Part two

Credentialing is the long pole

This is the thing that will eat your first three months. Everything else can be worked around. This can't.

Realistic timelines by payer

These are what we've actually experienced. Some go faster, some go slower, but plan against these rather than what you're told.

Which payer to start with

It depends on your state and who lives around you. Medicaid always takes longest, so if it matters to your population, start it first. We're near a military base, so TRICARE was our priority. Some payers aren't open for applications at all, and some won't let you participate until you have a certain number of staff. The honest answer is to pick the payer that will get you clients the quickest.

What actually delays an application

• Incomplete applications. This is number one every time.
• Incorrect information. Number two every time.
• Items lost in transit. Or so they tell us.
• After that it comes down to pushing and calling. How much time can you dedicate to being genuinely annoying?

Part three

Getting paid before credentialing finishes

You do not have to sit and wait nine months with no revenue. This is the part most new owners don't know about.

Single case agreements

A single case agreement is an arrangement with one insurer to cover services for one specific client. Most of the time they pay at in-network rates. Sometimes they'll only offer out-of-network rates, which is less, but it still keeps the child in services.

You use one while you're waiting on a contract to come through, or for a single client when you don't plan to contract with that payer otherwise, or when a family's coverage changes unexpectedly, or when their previous provider stops services.

Payers agree because they don't like lapses in care, especially if their network is closed or they don't have much coverage in your area.

How to actually get one

1. Call the payer and request one. Explain why.
2. Submit a formal request for services in whatever format they ask for.
3. They review the documentation and typically approve within two to four weeks.

Part four

What it costs, and who to hire

Most of this depends on whether you're opening a clinic space or working in homes and the community. In-home is dramatically cheaper.

Start with no less than three months of operating costs in hand.

The costs nobody warns you about

• You will not pay yourself for a long time. Unless you're the sole provider, expect this to take a while.
• If you don't have in-house billing, outsourcing it usually costs more than people expect.
• Staff want to be paid for everything, and competing with the big companies on pay is hard.

Your first hire

It should be a BCBA, as a Director or Supervisor. If you're not one yourself, you'll need one immediately for credentialing. Bring them in at least 30 days before opening. They need training and they'll become your right hand.

Before an RBT can see a client

This is state and payer dependent. Most require a certified RBT who has tested out and been approved by the BACB. Some payers let them work under the BCBA with nothing further. TRICARE requires certification of the RBTs themselves, plus malpractice insurance, a background check, a signing BCBA, and all of it submitted for approval. Budget 30 days for that.

Part five

Systems, and the audit nobody expects

You should have a practice management system before you open your doors. I know that sounds like something a software company would say, so here's the actual reason.

Without documentation you cannot bill. If documentation is lost or incorrect, assume that money is gone. Billing cleanup is far worse than getting it right the first time, because you lose the revenue and then pay staff to sort through the mess.

It's really a question of where you want to spend the money. Around $500 a month on a system that handles the clinic, or an extra $2,000 a month on a person to fix your billing. Start looking after your location is decided and credentialing has started.

Questions to ask any vendor

Including us. These are the ones that actually matter.

1. Are you genuinely all in one?
2. Do I need to attach anything else to make it work, or is there something else I'll have to pay for? Clearinghouse fees are the big one here.
3. Are you HIPAA compliant, and how is my data secured?
4. Can you handle specialties beyond ABA? Multiple locations?
5. Who is my team, and who is my go-to person?

The things I wish someone had told me

• Have a plan. When it fails, and it will, have plans B through Z. Being rigid is the fastest way to lose your staff's trust.
• Vet your leadership hires harder than you think you need to. You can teach skill and organization. You cannot teach passion.
• Be ready to be all in for three years before you take a break, a vacation, or a salary.