Why Negotiate Your Fee Schedule?
Most commercial payers start by offering ABA providers a fee schedule based on a percentage of the Medicare Physician Fee Schedule (MPFS) — even though ABA CPT codes have no Medicare rates. This often results in rates that do not reflect market value. Negotiating your fee schedule can increase revenue by 10–40% without seeing a single additional patient.
Know Your Numbers Before Negotiating
Before you call the payer's provider relations department, prepare the following data:
- Your cost per unit: Total staff costs ÷ total billed units for the period. This is your floor — never sign a contract where payer rates fall below cost.
- Your current effective rate per code: Total payments received ÷ total units billed, broken out by CPT code.
- Your patient volume with this payer: How many of your patients are covered by this payer? High volume = more negotiating leverage.
- Market comparison: What are peer ABA practices in your area receiving from this payer? MGMA surveys, state ABA association data, and networking can provide benchmarks.
- Your quality metrics: Collection rate, authorization approval rate, average days to submit, audit-ready documentation — quantify your value as a low-risk, high-quality provider.
Understanding the Standard Offer
Commercial payers typically offer ABA rates as a percentage of their internal maximum allowable charge (MAC) or a flat dollar amount per 15-minute unit. Common starting offers:
- 97153 (RBT direct therapy): $15–$22 per unit ($60–$88/hour equivalent)
- 97155 (BCBA direct): $22–$35 per unit ($88–$140/hour equivalent)
- 97151 (Assessment): $28–$45 per unit
- 97156 (Caregiver training): $25–$38 per unit
These starting ranges are negotiable — especially for practices with high patient volume or specialty credentials.
How to Counter
- Request an in-person or virtual meeting with the payer's provider relations and contracting team — phone negotiations are less effective
- Submit a counter-proposal in writing using your cost and market data
- Anchor high: Request rates 15–25% above your target — payers will negotiate down
- Propose value-based terms: Offer rapid submission turnaround (under 14 days from DOS), low appeal rates, and outcomes reporting in exchange for higher base rates
- Bundle the ask: Negotiate all codes together — agreeing on one code at a time often results in worse outcomes than negotiating the whole schedule
Contract Terms Beyond the Rate
The fee schedule is important, but review these contract terms carefully too:
- Timely filing limit: Negotiate for at least 180 days; 365 is ideal
- Clean claim processing time: Payer should be required to pay clean claims within 30 days
- Interest on late payments: Most states require payers to pay interest on late payments — confirm this is included
- Termination without cause clause: Negotiate for at least 90-day notice; 120–180 is better for ABA (patients need continuity of care)
- Audit rights: Limit the lookback period to 24 months for routine audits
- Rate floor: Request a "most favored nation" clause ensuring your rate is never lower than similarly-situated providers
When to Walk Away
If a payer will not move above your cost threshold for your primary codes (97153, 97155), declining the contract may be the right business decision. Accepting below-cost rates creates a financial loss on every claim. Practices that accept all payers at any rate often struggle financially — selective contracting at sustainable rates is a sound business strategy.