Scenario

You obtained your Board Certified Assistant Behavior Analyst (BCaBA) certification 3-months ago. You went from working as a Registered Behavior Technician (RBT), as you accumulated your required supervised fieldwork hours, to a position as a BCaBA with the same company. Suddenly, you had more authority to make decisions regarding your clients’ treatment programs, as well as an increased case load.

Shortly after you took on your new role as a BCaBA, you met with the Board Certified Behavior Analyst (BCBA) who is supervising you to discuss expectations regarding your new position. During the meeting, your supervisor said that the company manager has a requirement that you request 10-hours per week of one-on-one therapy for each new client the company serves when submitting your requests for hours to your clients’ insurance providers. Your supervisor also told you that you will be training RBTs to implement the behavior intervention plans (BIPs) so that you can oversee as many clients as possible. From your experience working with your current clients, you realized that not every client requires 10-hours of applied behavior analysis (ABA) therapy per week and you asked, “What if each new client does not require that many therapy hours?” Your supervisor responded that it is an unwritten company policy. Suddenly, you were faced with an ethical dilemma and you had to decide how best to handle the situation. 

Response

• Committee Input: 
• • Dosage should be directly related to medical necessity (there are no set minimum/maximums of treatment) 
  • • Recommendations include bringing proposed tx plan/assessment with dosage to review specific details (why your recommendation is less than 10 hours etc.) with Supervisor and BCBA. You can address this without acknowledging the unwritten rule – simply explain your treatment plan objectively with supporting evidence to defend your recommendation (think of it as doing a live or clinical review with the Supervisor). 
  • If this is unsuccessful, you should follow the ethical decision process outlined by the BACB to help guide you in next steps/reporting requirements. 
• Exploration: 
• • Access and review definition of medical necessity from the funding source (you could also use this as supporting documentation when meeting with Supervisor) 
  • Is there another program available? For example, does the company separate out types of services (consultative, comprehensive, focused?). It this is the case, maybe the 10 hours is the cut off for the focused model but this consumer could be supported in another capacity (like a consultative model) rather than a prescriptive dosage for consumers? 
• Relevant Codes: 
• • 2.09, 3.01, 4.03, 5.03, 7.01