The field of Applied Behavior Analysis (ABA) is undergoing a significant shift, but not in the way many of us envisioned when we first entered this profession. The introduction of value-based care (VBC) into the insurance funding model is reshaping how medically necessary ABA therapy is authorized—or, more often, denied. Instead of prioritizing individualized client progress, VBC emphasizes cost efficiency, standardized benchmarks, and "outcome-based" reimbursement models that fail to align with the personalized nature of ABA therapy.
However, an even more pressing ethical concern is emerging: Board Certified Behavior Analysts (BCBAs) employed by insurance companies are being asked to deny services without transparency, clinical review, or professional accountability. This raises a critical question: Are these professionals upholding the values that brought them into this field, or are they prioritizing corporate interests over client care?
How Did We Get Here? A Timeline of Red Flags
For those of us who have dedicated years to this field, the warning signs have been building for some time. We’ve watched the slow erosion of ethical decision-making in insurance-funded ABA therapy:
Initially, insurance companies introduced more administrative barriers, increasing documentation demands and setting arbitrary limits on therapy hours.
Then, they began inserting their own BCBAs into the approval process, shifting these professionals from treatment providers to gatekeepers of coverage.
Now, we are seeing insurance-employed BCBAs issue denials without clarifying questions, data review, or fair clinical evaluations.
When confronted, the most common justification from these insurance-employed BCBAs is, "It’s just part of my job training." But at what cost to the families and individuals we serve?
The Ethical Crisis: Denials Without Clinical Justification
Across the country, a troubling pattern is emerging:
Services are being denied without prior outreach to the treating BCBA. There are no clarifying questions or requests for additional documentation—just outright rejections.
Physicians conducting "clinical reviews" often admit they are not reading reports. Instead, they rely entirely on the insurance BCBA’s recommendation to deny services.
Families are left scrambling, forced to terminate therapy immediately while navigating a lengthy and exhausting grievance process.
This is not just an administrative issue; it is an ethical one. BCBAs are bound by a professional code that demands clinical integrity, transparency, and accountability. Yet, we are witnessing colleagues—those employed by insurance companies—compromise these principles under the guise of "just doing their job."
What Value-Based Care Means for ABA Providers and Families
The shift toward value-based care (VBC) is fundamentally altering how ABA services are delivered. While the concept of VBC may sound promising in theory, in practice it often results in:
Fewer approved therapy hours due to arbitrary benchmarks that fail to reflect the unique needs of each child.
Stricter definitions of what qualifies as “medically necessary,” leaving many families without access to essential services.
A rise in denials driven by cost-saving measures rather than clinical necessity.
This approach undermines the individualized nature of ABA therapy, which is designed to meet the specific needs of each client—not to fit into a one-size-fits-all model.
BCBAs, It’s Time to Hold the Line
If we, as a community, do not take a stand now, insurance companies will continue to exploit BCBAs to justify cutting medically necessary treatment under the guise of corporate efficiency. This is a pivotal moment for our field, and we must act to protect the integrity of ABA therapy.
What Can We Do?
File Ethics Complaints with the BACB: If insurance-employed BCBAs are issuing denials without proper review, they may be violating ethical guidelines. These actions must be reported.
Advocate for Medicaid Oversight: Patterns of unjust denials should be brought to the attention of legislators. We need stronger protections for families and providers.
Demand Accountability from Insurance Companies: BCBAs involved in case reviews must be held clinically accountable for their decisions.
Unite as an ABA Community: This is not an isolated issue. It is a systemic problem that requires collective advocacy and action.
A Call to Reflect: Are You Upholding Our Ethical Code?
If you are a BCBA working for an insurance company, it’s time to reflect on your role. Are your decisions driven by clinical need, or are they dictated by company policy? If it’s the latter, you may already be compromising the ethical foundation of our field.
We entered this profession to make a meaningful difference in the lives of individuals and families. Let’s not lose sight of that mission. It’s time to start a real conversation. Have you witnessed these issues firsthand? What can we do, as a field, to ensure ABA therapy remains focused on what truly matters: improving lives?
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