Waiving Patient Shares of Cost for ABA Services: What You Need to Know

If you provide ABA services, and you bill insurance companies for those services, you may have had families ask if you can reduce or waive their copayments, coinsurance, or deductibles. Maybe they’re struggling financially, or they’re just confused about how their insurance benefits work. While it’s natural to want to help, waiving these costs can lead to serious compliance trouble. Let’s break down what you need to know to stay compliant while still supporting the families you serve.

Why Cost-Sharing Exists

When ABA services are covered by insurance–whether by private insurance plans or public plans like Medicaid–these insurance plans usually require families to contribute a portion of the costs through copays, coinsurance, or deductibles. This setup is designed to prevent overuse of services and to help distribute costs fairly across the system. As providers, we have to respect these rules—even when we want to make things easier for families.

The Risks of Waiving Patient Cost-Shares

It might seem harmless to let a copay slide every now and then, but doing so can create big problems, including:

1. Breaking Your Insurance Contract: Most contracts you have with insurance companies explicitly say that you can’t waive patient cost-shares. If you do, you could be violating your contract.

2. Possible Fraud Accusations: Insurers see routine waivers as a way to misrepresent the costs of the services you provide, which can trigger fraud investigations. Additionally, routinely waiving cost-shares can be seen as an inappropriate inducement–an attempt to persuade clients to receive services from your organization.

3. Medicaid Violations: Medicaid rules require providers to collect cost-sharing amounts unless there’s a formal hardship exemption. Skipping these payments without proper documentation can get you into legal trouble.

4. Ethical Concerns: The BACB’s ethical code stresses honesty in billing. If you’re waiving costs without a clear, documented policy, it could be seen as unfair or misleading.

Real-World Examples of Impermissible Waivers

Here are three common situations where ABA providers could get into trouble for waiving cost-shares:

• Example 1: The “Goodwill” Waiver A small ABA provider has a long-time client whose parents mention they’re having financial difficulties. The provider, wanting to help, decides to waive the family’s copays for the next few months without any formal process in place and without documenting the decision and why they made the decision. While the intention is good, this likely violates most insurance contracts and could be considered fraudulent billing if not properly documented through a hardship policy.

• Example 2: The Competitive Discount A mid-sized ABA agency is trying to attract more clients and tells prospective families that they won’t have to worry about copays if they enroll their children as a client of the company. While this might seem like a smart business move, it’s a direct violation of payer agreements and could lead to audits, fines, or even termination from insurance networks.

• Example 3: The Phantom Bill A small ABA provider routinely charges and invoices all of their patients cost-sharing amounts; however, the organization makes no efforts to collect those amounts.  While this may seem like a “work around”, this does not relieve you of your obligation to collect cost sharing amounts and may be evidence of your knowledge and intent to avoid the requirement.

ABA Compliance’s Recommendations About What You Can Do to Compliantly Handle  Waiving Patient Shares of Cost

If a family is struggling to pay, there are better (and more compliant) ways to help:

1. Set Up a Financial Hardship Policy: Have a clear, documented process for evaluating whether a family qualifies for cost relief on a case-by-case basis. Your process should demonstrate a good-faith effort at determining true financial need. Make sure that your policy and process is clear, and that your staff understands it. Also make sure that you maintain documentation for situations where you agree to waive deductibles, co-payments, or co-insurance charges. This keeps things fair and transparent.

2. Offer Payment Plans: Let families break up their payments over time so they can afford services without needing a waiver. 

3. Point Families to Assistance Programs: There are nonprofits and grants that help cover ABA services—help families connect with these resources. To get you started, here are some organizations you might want to consider helping your clients’ families connect with:
4. 1. Autism Care Today (ACT Today!) www.act-today.org
   1. Provides grants for families to help pay for therapies, medical care, assistive technology, social skills groups, and other services not covered by insurance.
   2. UnitedHealthcare Children’s Foundation (UHCCF) www.uhccf.org
   1. Offers medical grants (up to $5,000) to help cover healthcare costs not covered by insurance, including therapies, equipment, and behavioral services.

Bottom Line

We all want to support families, but waiving cost-shares the wrong way can put you and your business at risk. Instead, set up a structured process that keeps you compliant while still making ABA services accessible. If you have questions about how to handle patient billing properly, ABA Compliance Solutions is here to help!