This week, I have Alex Grosso with me. He is a board-certified behavior analyst, and when I first met him, he was working in a clinic connected to a lot of school-based service provision, and now he has grown in his professional career across a whole bunch of different directions.And I could not be more thankful for the conversations that I've had with him over the years. It has helped me make sense of that medical model and where behavioral health services- where that line really blurs- especially for our students in school who are receiving outside services, and trying to make sense of how sometimes those services can be similar, but they are actually beholden to completely different systems.
So, Alex, thank you so much for joining me and trying to make sense of how these two systems can serve literally the same family or the same kid and still come from such different places.
Yeah, of course. Happy to be here. It's a long time coming, so I'm glad we can finally get this going.
Yes. So I'm curious: you've lived in both worlds. You've worked on the clinical side; you've supported students through that clinical model while they were receiving services within schools, too. What are some of those misnomers that are showing up for you? Where the school folks that you were working with, they just really didn't understand, and so something that seemed so simple and this would not be a big deal, you're jumping a lot of hoops to try to get that through. Anything coming to mind for you, which is like those misunderstandings where just people weren't understanding each other's systems?
Yeah, for sure. I think some of the biggest misnomers are just like an oversimplification of the whole process. They just think, "Hey, my child has ASD. They need services. Make it happen." It's not that simple. There's a lot to it. There's a whole process to this. And then, to an even bigger point, when services are already in place, sometimes an insurance company will be like, "Hey, it's time to start titrating down a little bit. We're going to reduce your services from X to Y based on the progress that you sent out to us." And then, to a bigger extent, that also causes a lot of confusion with educators and really a school in general, because they're just like, "Hey, we see that this child needs X, Y, Z services.Why are they cutting down? Why do you have to go down?"
And I think it's just very hard for an educator or for a school in general to see that when services are in place, at some point they've got to start reducing. And at some point, my whole purpose as a BCBA is to work myself out of a job and to hand off the baton to them so that way they can handle everything. The job of a BCBA is not to be there permanently. As much as a lot of caregivers and some teachers would love for us to always be there, at the end of the day, the child needs to learn these skills so they can be independent in that environment, because if not, you're going to have a shadow the rest of your life, and that's not the purpose of what ABA is supposed to do.We're supposed to help them reach those independent goals, those meaningful outcomes, and I think that gets lost in translation when cooperating with the school because they see us doing such a great job. Why stop that?
Well, I hear what you're saying from the clinical side of things; that you are supposed to be the add. That school is the given, and what you're offering is more. And I think sometimes that would probably be that lost-in-translation moment because sometimes it feels like you, as an outside provider, you're just now making us do all the same stuff you were doing. It's not that there were gains and, because of those gains, now fewer services or different types of services or a different environment is now more available for other skills to continue to be worked on or developed. I think sometimes it's lost in translation.
I mean, I'll be honest too, I think it's also like there are some shoddy service providers or different agencies out there, and they'll drop cases with little to no warning, and then that progress hasn't necessarily been made, and then the family's really left holding the bag at the end of that. So, I've been part of those situations. I know that that's out there, so I think that's part of that bad reputation around outside service providers and like, "Cool, we're out of here. You've got it from here." And it really feels like, "What were you doing?" And then you just drop this issue on our plate because in schools, zip code is their eligibility for services, not all of the hoops that I know you have had to jump through to just get the systems around you to validate that you actually do need to provide the services for this individual for these reasons.
Yeah, absolutely. Speaking of those hoops, those hoops are definitely some of the hardest things to jump through because if I get a brand new case, I have to sell to this insurance company, "Hey, this is why so-and-so needs X, Y, Z services at this level of care, at this intensity. This is what he is getting now. This is what he's not getting right now." And I have to lay that out bare for them to see, "This is the picture that I'm painting for you guys. This is what this child is going through." And it could be very hard to breach that, because again, you said, you kind of hit the nail right on the head, there's a lot of shoddy providers out there that do things sketchily, which scares off a lot of these payers, these insurance companies, from wanting to give those services, especially school-based services, because there's a whole facet of different issues when it comes to school-based services.
Are the services being duplicated? Meaning, are these accommodations that you are bringing to the school already in the child's IEP? If they're in the child's IEP, why are you doing them again? The school should be handling that. But then, on the school side of things, the school could be underfunded, and even though they have those accommodations in the IEP, it could be very difficult for them to provide those accommodations. So, that's why the RBT is potentially there to kind of help out. But at the same time, that's not the RBT's job, and that's how the insurance company sees it. So, it's like a lot of he said, she said, that way, this way, back and forth.
And the thing is, both sides are right. The insurance company is not paying for an RBT to go to a school to be a shadow. And the school also needs support from the RBT, but they can't be, again, doing what the school should be doing.
And I think it's my job as a BCBA to kind of bridge that gap, to help the educator understand, "Hey, this is why this is happening, and this is why we can't do this." And also, at the same time, make sure that when I am submitting my plan to the insurance company, I am reassuring them, "Hey, I am not doing X, Y, and Z. The school is doing that." And that could be a very hard tightrope to walk, because needs change every day, and an IEP meeting happens once a year.
Right. Well, so let's talk about this, because I think there are different, I think, mechanisms really in both structures. So, yes, an IEP has to happen at least once a year. If it's a hot case, I've had some that are being revised every month because there's significant change or all kinds of different pieces that then really do merit a full update. But when you're working with insurance, it is not only every year. That's not the minimum. Your minimum is much more frequent than that. But I also think in education, we have plans, we have IEPs, we document the present levels, and we have the reports of progress or lack thereof with the goals and the interventions aligned with it.
We have those things, but that is not what you are then taking forward and then having to convince insurance providers to approve you to provide those services. As an IEP meeting, collectively, it's one of the reasons I love education: it's multidisciplinary. You get all the people, all the experts at the table that understand all the different pieces of what is going on with that kid, and you pool it all together, and you put that into one document to the best of your ability.
But kind of then if that team agrees, then you just go. You don't have all these additional pieces that you are very familiar with, where, okay, cool, you run all the data, you write the plan, you have all the... But then you have to go convince someone who doesn't know the kid, doesn't know the context, doesn't know anything, to say, "Yeah, you can do that." And I think that's a different level that I really don't think many educators are familiar with. If anything, like Medicaid billing, you just document your time, pass it forward, maybe forms change, or different providers change, whatever. But the actual, "I have a plan that I am now going forward for specific approval to even be allowed to do that," I think that is a very different process that you're very familiar with, and I think that's really not as familiar in education.
Very important thing that you said: they only know what I'm telling them, so I've got to make sure what I'm telling them is to the point, as detailed as possible, but not overwhelming. Because in some cases, depending on the child that you work with, it could be very complex, but I've written reports that could be 200 pages long, and the last thing that somebody at an insurance company wants to see is a 200-page report. Now, mind you, they'll review it. They have to. It's their job. But that's a lot on them on top of the hundreds of other plans that they're reviewing that day. So it's, again, a very rigid tightrope you got to walk, where you're getting to your point, you're showing your progress, you're showing what needs to be done, and you're showing why these services are needed to the insurer.
And then at the same time, you also have to make sure that what is happening at the school is all according to the plan that is written out for this child. And also having to explain to an educator like, "Oh, why can't you be a shadow like Johnny's RBT over there?" It's like, "Well, I don't know what Johnny's RBT is doing over there, but I'm telling you what the insurer is telling me that needs to be done, and the insurer does not want me doing what Johnny's RBT is doing over there, and I'm not going to have my RBTs do that because that's not ethical.That is not part of the plan. That is not part of what the insurance has me here for."
At least here in Florida, and unfortunately, it's become kind of a standard where ABA in the classroom, okay, that's just kind of a glorified shadow for an RBT to be there just kind of hanging out. I've seen some horrible things where the RBT is on TikTok while their child is having a tantrum right next to them. And then it kind of makes you feel like you're the crazy one because you're doing everything by the book, you're being ethical, you're kind of telling the teacher, "Hey, I know what most of these RBTs are doing, but that's not what we're doing." And being firm and standing in that. And you can sometimes rub some people the wrong way because you're so staunch.
That's what I was just thinking. I was like, I think what you're explaining is the reason that sometimes outside service providers come across as being stuck up, standoffish, too strict, too rigid. Those kinds of things. But in education, we're on the hook for meeting kids' needs; sometimes it feels like no bounds. That literally any need that is part of that student, education is on the hook for somehow providing. Where what you're talking about is, if it is not in this plan, I am not allowed to do it. Even if I wanted to, I can't. It's just a very different system.
It is just a completely different dynamic where you're like, "I did speak up." Even if I agree with you, I can lose our backing, all of those things. As a provider who is beholden to insurance, if you then step out of line, there's a lot to lose there too, which is, I think, where some of that rigidity or that maybe standoffishness or that kind of look may come across as educators; that's not part of our game.That's not even a consideration, where it's so real for outside service providers and your funding models. So I don't know. Would you be willing to put some more words around that? Because I think that in education, we really don't have a whole lot that's commensurate with that.
I think something that's really important to take into consideration when it comes to the funders and the payers in this situation: insurance providers are going to be like, "Okay, well, he's in school. He has an IEP, and the school provides accommodations. They should have speech. Why is speech not happening? Oh, he should have occupational therapy. That should be offered in school." And those things are offered in school.
So it's even crazier because now I have to be like, "Well, those things are happening. Those are happening in 30-minute increments between classes or sometimes in the middle of a class." A speech therapist will just pull them out, and we'll go into some random room. We'll do speech for 30 minutes.
And then, to a bigger point, I have to also collaborate with the speech therapist and the occupational therapist and be like, "Hey, this is what we're doing. This is how we're working on it. These are the communication goals that we got." And then I have to take that to the insurance company and be like, "Hey, this is what they're working on. Just to give you an idea of what's being worked on in school, this is what we're working on. We're collaborating on that."
But despite our efforts, I have to tell them his communication isn't there, and that's the key thing that insurance providers are looking for. They're looking for: what is your need there if this is already happening? “Hey, how are you working together to work on these deficits without duplicating the services?” So it's like a crazy tightrope, as I said.
That's where I think I've worked really well with outside service providers who see the whole picture of the student and see how many different people can meet all of these different types of needs that are showing up. So it's like, "Well, I couldn't get what speech is doing in the school covered through insurance, but I know it's a need for this kid, so I'm going to collaborate with the people who do have that approval for whatever those services are to make sure that that entire experience for that individual is actually cohesive." So I've so appreciated folks that are willing to see the bigger picture of who this individual is, what they need, and where those needs can get met, if that's inside of school, if it's outside of school, all kinds of different creative angles.
Honestly, I've seen a lot of different really cool ways of leveraging what different systems have to offer, and then that way nobody's double-dipping, but the individual's actually the better for it because they've gotten multiple systems to work on behalf of them. But man, that's really hard to make happen, especially when it's kind of on you.
You just have to prove to insurance that it is or isn't needed. You have to have the documentation that you can convince someone who has their own professional thoughts to see your situation the way you see it. And then, because it continues. That's just approval to run the plan. That's not then ongoing oversight, which in education is really done primarily through case management, maybe some local education agency oversight.
And there's documentation around fidelity of implementation and those pieces, but it is nowhere close to the level of detail and documentation that you need to have to then be able to go back to insurance to say, "Hey, I know you approved this thing.We're actually doing it. Here is how we're demonstrating if it is or isn't working, what adjustments we are maybe then asking to make to it." Or like, "Can you walk through what that looks like?" Because yes, it's a bear to just get the yes initially, but that's not the end of it. There's so much more that's then all tucked in throughout the entire service provision as well.
Speaking on my previous experience and being in a lot of schools, when they have a child that maybe is engaging in a lot of target behaviors and maybe is struggling a lot, a teacher just wants somebody with them all day. Sometimes the school can't provide that, but they want somebody. But my goal when I observe a child is to see where they're at. Maybe in the classroom, they're acting out, engaging in more behaviors because they're left to themselves, and maybe the classroom management strategies aren't as effective. And I mean, I've seen that happen a lot. So they just kind of want somebody there with them to kind of manage them.
And that's not the job of ABA. Our job is to teach them the skills. During those observations, whether it's at the home or I'm watching them at school, I'm kind of figuring out what level of care is best suited for this student. And sometimes that level of care is not going to match what the teacher wants. The teacher wants somebody there 30 hours a week, maybe 35 hours a week, from 7:00 a.m. till 3:00 p.m. That's not... No. That's not going to happen because that just ends up being a shadow.
Well, and I mean, in schools, that's where we would be looking at, like, that's a paraprofessional, or that would be internal staffing. That's not an additional support or service. That's a full-time one-on-one, which has its own proof points and documentation and a variety of different meetings that would need to happen and hiring approaches. So in order to walk that level of care strictly through education, there are also some hoops that we'd need to jump for that level of care, for sure.
Yeah. Well, I know a lot of this conversation we've talked about oversight and documentation and the strictness and really, the onus of the professional to be able to communicate and defend both the case, the practices, the need, the outcomes, all of that.
But I do think that there is something to be said for having that almost third party or the outside, or the person who's not intimately interwoven into all of the services that are providing, or that are being provided. Because I almost kind of think that there's a specific quality standard that is like, "This is what is expected here." And without that type of a mechanism baked in, I kind of wonder if it would then just be like, "Well, colleague to colleague, we both said it's fine, so it's fine." As opposed to like, "Oh, we have to actually convince someone and then actually prove to someone who isn't here, they don't get it, they're not seeing it." So I'm wondering, what do you see as the benefit from having that outside, unfamiliar level of oversight?
Obviously, the results speak for themselves, you know? When at the end of the day, after a six-month authorization period, what I'm presenting is the results of those opportunities that those RBTs had with the student, having fun, teaching them skills. And I show them that evidence with all the data that I collected, the data they collected, and also ensuring that the data is being collected correctly, which, you'd be surprised, does happen. It does happen. Sometimes you get an overzealous RBT that will count every instance of touching someone's arm as physical aggression. I'm just like, "That’s not how it’s defined." There are examples there.
That happens in education too.
So now I got to throw away all that data because this kid went from barely engaging in any physical aggression to now hitting a hundred in one session because he was tapping you. So, oversight is also making sure that everything is being done as written and as introduced, but also letting the RBTs have the freedom to do what they need to do in order to teach that skill. And then also making sure that when the documentation is being put together, the data makes sense.
Something really great that I used to do in my clinic is that we would do monthly audits.We would go back, we would review every single graph, go through everything, talk to my team during a session, be like, "Hey, give him a little break, and we're going to kind of go over these graphs, and I want you to explain what's going on here." Or even when I didn't do an audit, if I was just supervising, sitting there with them, I would just be like, "Hey, what's going on here? We were at a model prompt, and now he's struggling. What's going on?" And always being meticulous with the data collection, finding out if there's an issue, and being on the same page as the people who are interacting with the kid every single day.
Because as a BCBA, you have multiple cases, and you're kind of making sure that everybody's doing well. And if you're a good BCBA, you're seeing your kids once or twice a week. You're not letting it go for a month and then coming in and being like, "All right, let's see what I can fix in two hours." And then, yeah, when it comes to the end of it, after a six-month authorization, if I'm doing my job correctly, if I'm auditing, if I'm getting to the bottom of why data can be a little weird sometimes, if I'm doing all that correctly, when it's time to present my case to the insurer and be like, "Hey, this is what we still need.These are the hours that we're requesting. This is my data. Have at it."
If I'm not doing my job correctly, if I'm letting these graphs get crazy, and I'm not seeing the child, I'm not seeing the RBTs. If things are not being done the way that they should be, then that's where you run into issues. It's also important that, yeah, you might have the data to prove your case for 35 hours, but insurance companies will look at it with a magnifying glass and be like, "Okay, well, this is going to have to go to secondary review." And then the last thing you want is to go to secondary review, because then you've got to talk to a doctor, and then you've got to explain why you let six months go without making any changes to your intervention.
And that could lead to some pretty serious consequences. It could lead to them being like, "Well, if you're not good at your job, then maybe these aren't the services that are needed for this child." And maybe they might recommend that they try other services, or maybe get medication, or do this or do that before they allow you to have 35 hours, because you had it and you did nothing with it.
Can you explain what secondary review is? Because I think the only mechanism similar to that in education that I've come across is almost like a due process situation. But that typically comes through a family complaint that progress isn't being made, and I'm not okay with how this educational experience is going for my kid. Then other people get involved. They start digging through the records and the data, the progress, the lack thereof, the interventions that were selected, implemented with what fidelity. Then that's in education where that gets really ugly. But in your systems, you're talking about that as a mechanism. There is something that would be triggered, and then it would automatically go to secondary review. Can you just explain a little bit more about what that is?
Yeah, of course. So, after a six-month period, I work on my authorization report. My authorization report is going to have the progress that this child has made within the last six-month period, as well as maybe a little summary of what's going on, talking about strengths, weaknesses, and the progress made, of course. So, let's say I was bad at my job and I just kind of was like, I already had a 32-hour authorization request approved, and I was like, "All right, great." But my child did not make much progress, and I was not trying new interventions. I was not showing evidence of what I was supposed to be doing. I just kind of let it happen for six months. And then-
And that would be in the report that you're pulling? Like, that's you documenting all of those things and then the provider noticing those gaps?
Right, exactly. So then the person that's reviewing the report is going to see that, "Hey, physical aggression was at 100 instances at baseline, and guess what? Now it's at 150 instances, so that's an increase. What's going on here?" And there are no phase change lines. There's nothing indicating that new intervention was incorporated. There's nothing stating that you've made any progress on any of your STOs. So right there, the reviewer is going to see that, and that's going to be a big red flag. They're like, "Something's going on here."
Then it's going to secondary review, and it'll be reviewed by an MD, a medical director. And the medical director can potentially be a doctor, can be a psychiatrist, can be a psychologist.It could be people who can essentially give the CDE, give the diagnosis for ASD, and give the recommendations. It gets back to them, they review it, and then they're going to look at that plan, and they're going to be like, "Okay." And then they're going to make their determination. They're going to be like, "Okay, I don't think this should be at 32 hours. I think this needs to be reduced," or, "I think this needs to be denied."
So basically from there, I'll get a notice of that, and then I will be told, "Hey, this was reviewed by one of our doctors at the insurance company, and we determined X, Y, and Z." So let's say it was a denial because I was bad at my job and I did not do what I was supposed to.Then my option from there is either I can appeal it by providing additional documentation as to why X, Y, and Z happened, which is a whole process in itself, or I go to something which a lot of BCBAs dread: peer-to-peer, meaning I am going to go talk to the doctor and I'm going to have to explain why I did such a bad job for six months. And you never want to go to peer-to-peer. You always want to try to avoid peer-to-peer by doing a really good job, but sometimes things are out of your control.
It sounds scarier than you think, but at the end of the day, when it comes to that first reviewer and then the medical director reviewer, they're just doing their job, and they're just trying to make sure that the services that we're providing are appropriate for the student, and they just may have additional questions. And if you just answer questions confidently and you know what you're going to say and you really lay it down thick, you're not going to get too much pushback.
Yeah. Thank you for walking through that, because there's really no commensurate process that is like that within education. And so even though we talk about providing services and identifying needs and tracking trends over time and all of that, that type of a structure, that type of a system, really, there isn't a mechanism for it. Unless, at the local level, a special education director has chosen to sort of run their department more through that clinical director role where they're pulling cases and reviewing progress and spot-checking documentation.
It really isn't until there's a complaint that, a lot of times, a file gets pulled and actually gets that review. And that may or may not even be with any other experts at the table. It may just be that local team or within the district itself, too.
Well, before we sign off today, I'm curious: what are some things that educators or school teams can do to really partner well with outside service providers who are just simply beholden to different systems than what the educators are?
I think that's really tricky because I feel like the waters have been very muddied as to what outside providers are supposed to be doing versus what they are doing. I think one of the most important things is for educators to be understanding. Yes, maybe this ABA company is working with this member this way, and that's how they're doing it, but that's not how they should be doing it. So, they're so used to a lot of RBTs being a shadow. They're used to a BCBA maybe coming in once or twice a month.
So I think what I would love is maybe for teachers to be very understanding that not all agencies are the same. You're going to run into people like me, and you're going to run into people like Johnny ABA over there that are going to do a very different job than I'm going to do.
And when the right way comes in, I would love for an educator to be like, "Oh, okay, this is how it's supposed to be done." And be open to hearing out what the BCBA is recommending, and just collaborate. Collaborate is one of the biggest things.
I know, at least in my experience, a lot of educators were always kind of taken aback when I would try to be so collaborative, because they just weren't used to it. They weren't used to seeing a BCBA as often as they would see me. Collaboration, at the end of the day, that's what I always found worked the best. When I was able to get that in with the teacher and get that rapport built up quickly, those asks didn't become so daunting because they saw the work.They saw the progress. They saw the client that I was working with improving.
So, I think it's a lot of ‘show your work.’ So, when they would see that progress, when they would see the reactions from my clients, when they would see them improving, and they're like, "Okay, you're onto something." So yeah, I think that's my big takeaway.
Well, thank you so much for just explaining things that are second nature to you. It's your practice, it's your profession, it's the way you have shown up and cared for individuals that come across your path. And I truly have learned so much from you over the years in making sense of what I don't have experience in, but yet so many of our systems or service provision starts overlapping or blurring, like you're talking about.
So truly, thank you. Thank you for putting some of those words around it. Thank you for choosing to be that good provider, to be the person who is showing up and doing right, not just by that individual, but also working those systems on behalf of the outcomes that you know are very real and can actually happen when it's just done well. So, thank you so much for showing up and putting some words around this with me tonight. I really appreciate it.
Oh, of course. It's always my pleasure. I'm glad we were able to do this.
