Illinois Considers Legislation to Unwind Applied Behavior Analysis Restrictions

Per recent Illinois legislation, Board Certified Behavior Analysts (BCBAs) in the state are now required by law to become licensed, and by January 1, 2027, owners of Applied Behavior Analysis (ABA) businesses must also become licensed. Meanwhile, two bills have been proposed in the Illinois Legislature this year that removes the requirement that owners of ABA businesses be licensed and contemplates BCBAs owning professional entities. John Saran, Partner, Holland & Knight LLP, speaks with Karem Alnatafgi, Founder and CEO, Peak Behavioral Services, Inc., and Veronica Glickman, Founder and CEO, Autism Behavioral and Educational Services, Inc., about the impact of these new licensure requirements and how the industry is adjusting.

Watch this conversation: https://www.youtube.com/watch?v=6GhihdKX0_E

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Transcript

SPEAKER_01 0:04

This episode of AHLA Speaking of Health Law is brought to you by AHLA members and donors like you. For more information, visit americanhealthlaw.org.

SPEAKER_04 0:17

All right. Well, welcome to this next edition of a podcast for AHLA. Today our session is actually called Illinois Considers Legislation to Unwind ABA Restrictions. And before we kind of jump right into the topic, I'll have uh each of the uh podcast uh panelists uh introduce themselves and then I will I will go last. Uh but first let's start off with uh with with Kareem.

SPEAKER_00 0:42

My name is Kareem. I'm the founder of a small ABA practice um in the Chicagoland suburbs. Um we're in the Forest Park in Naperville, Illinois. Um over the we've been open for about three years. Over the past three years, we've serviced um a couple dozens of families, um more so focused on families covered by Medicaid. Um so it's uh it's been a little bit of a challenge with the nuances with state regulations now that these now that the topic of today is um discussing the um proposed bills, and and I I've been currently going through a restructure for the organization to be able to adapt to these changes legislatively. Um I'm more than happy to share more information about that.

SPEAKER_03 1:37

And hi, I'm Veronica Glickman. I'm the um I'm a licensed uh board certified behavior analyst. I'm uh the founder and CEO of Autism Behavioral Educational Services. Um we have clinics operating in Illinois as of 2010, actually. And um we we're here for the ride. We're here to see what happens. Um, I know the impact to us may be a little bit different, but there is still a significant impact. Um so I'd love to continue this discussion.

SPEAKER_04 2:10

Yeah, thank you both. And uh I'm uh John Saran. I'm a partner uh at Holland and Night um in our healthcare practice. Uh I'm actually part of the Chicago office. I've pretty much spent most of my life uh in the Chicago area, grew up in the southwest suburbs, places where you all have clinics, currently live in the northern suburbs, uh do a lot in Illinois, and uh it has been it's been interesting kind of uh monitoring uh these uh these you know these changes um because it it is unique and and and I think that's kind of a good segue into um you know what's sort of why we're talking about this. But I think in and before we get into the proposed bills themselves, I think we kind of can just talk about the underlying law and sort of how that how Illinois um you know fits in with the rest uh of the country. Um, you know, so just generally and and and folks that know healthcare, um you know, they they understand, right, for physicians, there are licensure requirements and you know uh the ownership requirements for operating physician practices. And then over time, and that's been around for like a hundred years. I mean, that's been a lot around for a long time. Uh and then you know, as as other types of providers have have come onto the scene, um, you know, licensure requirements have um have also, you know, there's been licensure boards that have have each of the states have had, and the like you know, the laws are different. Um, but for BCBA specifically, um, not every state has a licensure requirement. Um, you know, there's the board certification requirement. Um, and when I first started practice uh you know a while ago, um, you know, there were really not many states at all. And then now I think it's 40 states or almost. I mean, we're we're getting closer to 50, but it's not it's not, you know, you know, every state or nearly every state like the other uh licensed practices. Um and Illinois in particular, you know, a few years back, um passed some changes to laws that would require uh you know licensure by BCBAs. And I think it was this time last year, um, you know, the spring of 2025, uh, you know, where uh BCBAs had to get licensed in Illinois. Um, obviously it was a new process, so I'm sure there was a lot of, you know, uh there's new forms and new um not only you have to, you know, credentialing and then you have to work with your payers to, you know, for verification and all that other stuff. So uh given that literally that just happened, right? And it's been hasn't been that long um in sort of implementation. So what do you what have you both been facing with, you know, with the new licensure requirement and you know, for you yourselves and then also your you know your employees and your partners, um, and how you know those discussions have gone uh also with like payers and other stakeholders.

SPEAKER_03 5:07

So um I'll start that off. Um as a VCBA myself, um, we did have to get licensed. Um the open window for licensure in Illinois was um a very short open window, like when the actual system became active and for everyone to then bombard it with um, you know, applications yet to get re-fingerprinted, um, which is kind of a requirement anyway. Um, before anyone starts a job in our in the company, we have to have them all fingerprinted. So that had to happen, and it was a different type of um like form that needed to be submitted to the state. Um it wasn't like the background checks that we typically do. So we, I mean, it was rushed. We had to make sure everybody was in on time. And um, you know, with one of our BCBAs, her fingerprints were sent elsewhere. Um and that for us as an agency, as an organization, we did encounter like the insurance companies have policies and requirements. And I'm like, well, what happens if, let's say, this BCBA is a board certified behavior analyst, but she's not licensed as of the state. So um the insurance feedback, at least to me, was well, you can take the risk, like, but they can't come back and recoup the money from from you if that was, you know, the services were overseen by uh a BCBA and then not a licensed BCBA. So for me, who is an operator, who was also a BCBA, but operates a business. So a lot of my work is really not um in the clinic per se overseeing patients. Like I had to stop everything that I was doing because I didn't want to take that risk. And then I was there supervising because I was licensed until we were able to get that push through. And that really was more of a call every single day to our licensing board um in the state, going, hey, um, when is this gonna happen? Can we make sure that this happens? You know, it was just like this push, and they're like, well, this could take so many days or so many months. But that to me as an agency, when we are, we are a smaller agency. Um, so to me, to then not be able to have a BCBA and then not be able to bill for the services that um she's providing, it does take a hit, you know. Um luckily I have the ability to drop things and then jump in myself. I always keep myself credentialed. Um, so like that's that's that piece right there. Um, but it was um, I'd say it was kind of like, yes, we've decided, yes, they pushed it off to a certain time frame. And then they also gave us um uh uh a two-year uh licensing and then they modified it to uh just that to like the end of 2026 um or 2025, and then we had to reapply for it. They waived the fees, but it's again, it's like that process of like we just started, um, you gave us like certificates that are licenses that state at a certain date, and then we're uploading that, you know, and and maybe going into too much detail, but you have to upload that to your CAQH so that you know put the dates in there and then have to go back in and test and then and that all runs through, you know, through all of our insurance companies run through all that. So then we had to go back in and then modify everything. So it's just a lot of extra, extra that we needed to get done. Luckily, we were in compliance with everything, but it wasn't exactly, you know, uh the most pleasant moment, but it wasn't as I guess as bad as it could have been. Kareem, what about you?

SPEAKER_00 8:21

We had a little bit of a hard time um when this got implemented um because we had a couple of providers actually moving into the state of Illinois. So they were either not licensed at all or licensed in other states. So there was a few barriers there on trying to get them in Illinois licensure. Um, and it is a little bit difficult because I um, us being a smaller practice, we go into phases where we really need providers as soon as possible because our demand is so high. Um, so having we've started looking out of state for providers and hopefully relocating them to the state of Illinois so then they can service our clients. But then having this additional step now was a little bit difficult because we just can could not meet the demand as as quickly as we needed to. Um but then on the other hand, like uh Veronica mentioned, it was a very confusing time when things were first implemented because the BCVAs really needed the extra layer of support from um an operations person within the company to kind of give them all the instructions on how to do things. So it took all the extra due diligence from our our from myself and the operations people at the company to walk through step by step and make sure that the BCVAs get this done. Um so then we are in compliance, right? But um, we definitely did face some struggles in the beginning of licensure.

SPEAKER_04 9:46

And have you, I mean, now that the dust is settled and everything, are you both sort of working on, you know, like in internal processes, right? To make sure that everyone gets renewed and if there's any outreach on any issues, right, that those are taken care of so that nobody lapses and you know, then you don't have issues with billing and otherwise. I mean, so I think it's a two-part question. One, you know, are you starting to build sort of those internal operational processes? And then two, has, you know, aside from the you know, initial kind of engagement to get those licenses, has there been any sort of follow-up or you know, checking by either the state or you know, payers, you know, um, now after the fact, right? Like, are you licensed? You know, almost like an audit. Um, has there been any audits yet?

SPEAKER_03 10:33

Um they no, because we have to very like we have to re like verify our data, our directory information with insurance companies every 90 days. So we're able to go in and like make sure that information's in there. Um, we definitely have built in uh protocols so that there isn't um there isn't a lapse in licensure on our end. So we have policies that we created, and I mean, and it is tied to some, you know, a BCDH job requirements and and so that they have to be licensed in order to continue working with us. And um, and I I'm lucky we have a great team of people who are all about on board, but but yes, I'm so we are we're ready, but there's really not been any reach out from insurance companies, at least at our company, um, asking if everyone's licensed, just because we like I guess my goal was to really just have it all there so that there wasn't gonna be any issues. And um, Kareem, like you were talking about like operations, I actually went myself first to see what the process was going to be like with fingerprinting so I could experience it and then send out an email to my VCBAs going like these are step by steps of what you need to do by what date. Here's a place to call. I mean, we default to certain places for fingerprinting. So they knew, and because we've been with them for so long, we they knew that this needed like this was urgent. They did like you know they would schedule those appointments. Again, having those relationships are great. Um, but um I had I went through it myself first to experience it so that it was a smoother process for my staff.

unknown 11:59

Yeah.

SPEAKER_00 12:00

I think the other quick thing would be to mention is the initial licensing fees were pretty high. Um, so that was a pretty significant expense that just came came to our table. Because we I think at the time we had seven BCBAs to license, all within the same month. So um we obviously had to reimburse as an organization um for that licensure, and then we had to come back and and put some um terms and conditions in there if they were with us prior to this and into their employment agreement where, hey, if if we reimburse your licensure and then you leave within the next month, what would happen, right? Because that's a pretty significant expense for uh at least for a small business uh at my size or a startup at my size.

SPEAKER_04 12:44

Yeah, that makes sense. I mean, yeah, there's the cost not just for the license, but then the implementation and and then um, you know, just the recertification and whatnot. So and another part of that bill, just kind of shifting topics, um, the original like the existing law today, uh, there's a section that essentially requires um section 150 that requires uh by January 1st, uh, 2027, which is coming up here, uh, you know, in the next nine months or so, um it requires that owners of ABA businesses be licensed uh in the state. And that requirement is not new for the you know, if you're talking about again, a physician or a physical therapist, uh, you know, or other you know, healthcare license type. Um but for BCBA specifically and and the licensed behavioral analyst, there's only today that I'm aware of, there's only one other state, New York, that requires that. Um and because behavioral health is different. A lot of you know a lot of your practices, you'll have three, four, five different license types, you know, uh counselors, uh social workers, physical therapists, BCBAs, you know, physicians, psych psychiatrists, you know, psychologists, psychiatrists, like everyone kind of working together. And so you, you know, it it's it's been an interesting uh dynamic for the for the industry. But as of you know, originally it was just New York, and then now Illinois has this requirement. And you know, you had they built a runway in you know, in the law, right, January 1st, 27, uh to make these changes. But you can't just like snap your fingers and all of a sudden you you've you've you you're sort of your structure, your your comp your model is compliant. I mean, there's a lot of things, I'm sure, cream, as you know, as you're experiencing, that you have to do, right? You have to move contracts, you have to move sometimes employees, you have to move benefits, you have to form new entities potentially, you have to um, you know, maybe split apart practices now because you can't have the BCBAs with you know your social workers or or or whatnot. Like and that, and for what I've seen for my practice, um, you know, I would say sometime around last summer, I started getting calls about this, you know, this requirement. And um, and I would say probably in the last month or so, I've received a lot of calls about this. And I think it's because people are, you know, right, sort of planning ahead for the year, and they're like, okay, it's you know, Q2, it's coming up, like we gotta, you know, and and also, especially if you're moving people or major things are happening, you probably want it to be at the end of the year or the start of a new year because you don't want stub periods, you don't want, you know, that's just gonna make it even more complicated. Um, so I've started to receive a lot of calls um on this point. Um now, obviously, you know, and what I've seen too is that, and this is affecting everyone. This is affecting the very large, the largest end of the spectrum of practices, and then the very small. Like there's no, there's no like threshold, like, oh, if your revenue is over this, then you have to do it. It's it's everyone, right? And so if you're a larger practice, you may have the resources, you know, to engage with like a you know, a law firm, um uh national law firm to do it, um, and you may not. So I'd be curious uh to hear sort of you know, the two of you, sort of how you have been thinking about this, you know, when obviously it's been around for a while, but now that we're getting down to the wire in terms of you know that deadline, sort of how are you planning for? What are you thinking? Um it sounds like you've already started, you know, uh, Kreem, you've already started um you know engaging in some of the at least planning or potentially even starting to move things around. I'd be interested to hear you know how this has affected you um both, and then also just from what you've seen out there in the market, what you've heard from your other fellow operators and other, you know, um uh you know, licensed uh licensees. It'd be great to understand that.

SPEAKER_00 16:57

Um I think from my perspective, I'd really like to mention first and foremost, is I've I've seen a lot of um colleagues and friends of mine that also own practices be very worried about this. And then a few folks that are like, I just don't want to deal with this, I'm gonna leave the space, which is brings to the next point is like some people just may not have the resources or the bandwidth to go through all the hoops that that need to happen within that um time frame. From my own experience, I start, I was planning pretty much from June of last year. I started setting up plans of how things are going to move around. What am I even gonna do doing my research, doing consultations with um an attorney and trying to figure out how to structure the organization so then we survive this, right? Because we are not we're not structured in a way that we can still operate in 2027. Um by November, I had a pretty solid idea of how things will and how things will start rolling out. And then I started pretty much like 80 to 90 percent of my week is is trying to figure out this restructure, right? So then with with that um amount of time being allocated to this, I had to bring on more operations people to run the business. I had to bring, I have to um put on a lot more overhead and a lot more salaries to be able to still operate things. And since I'm taking myself out to be able to structure this, um I've noticed a lot of difficulties while trying to do the the um the planning and more and more every day trying to figure out, oh, this has to change too, right? I didn't even think about this. Um, biggest there's a lot, it goes a lot deeper than just a couple of forms and a couple of attorney consultations. It's your entire structure that's already built, undoing it and redoing it all over again, right? Um also there's a lot of nuances of I'm I'm of trying to explain to my attorney this is how things function within our space, right? It's not a cookie-cutter approach of um a medical practice does this, so then we do this as well. The operations are so different um from other um other specialties that that are bound to to CPAM. Um so it's definitely been a hurdle and very, very, very expensive hurdle to to overcome.

SPEAKER_03 19:30

Um as an a B C D A owner, I'll I'll tell you, I mean, like to me, I think this is yes, you know, like we have to change a few things. It is costly. We are a small company. Um, at least I consider as a small company, it'd be nice to be able to put the money towards resources and services and quality instead of doing that piece of it. Um, and I think um speaking to colleagues um in the field, yeah, they're looking to leave the space. And as a company that is established here, let's say people leave a space, leave Illinois. My concern is where are these kids gonna go? The ones that are currently like there's not enough providers to begin with. So now we have um currently, then we'll have a bunch more kids. And like I cannot onboard children with autism as quickly. I mean, we it takes us a month to train a staff, like an RBT staff. So and then to find the staff, right? To be able to do that. We can't just like recruit people from there. It's also people are gonna lose their jobs if companies close down. And it, I am not looking at it like, oh, we'll have more staff. It has to be a right fit. And it it takes time to train to make sure they meet all the competencies before we're able to, so these kids are gonna go through like either not have access to services, or it'll be and all the work that's been done could possibly like fall into regression at the end of the day, you know, and that's like all this time spent um with making all these strides and progress. It's it's at the end of the day, it's really impacting the kids. Um, like, and we don't take um, we don't take Medicaid because of their fee structure. Um, so for me, like companies like Kareem's, like they do take Medicaid. So if he ends up leaving the space or or not doing this process, where are these kids gonna go? I mean, at the end of the day, it's like where and I am a I do, I'm a BCBA, but I most of my job is operations and finding, I mean, like it's I'm running the company as a whole. And my the clinical decisions, and I think, you know, like to me, CPOM is like their whole point is like to make sure that the clinical decisions I made by BCBA or my clinical decisions are made by a clinical director. So like that does not change how we run the company. Um, no matter what structure we're in, like I'm not involved in that aspect of it. I have someone making those decisions. So to put that out there, and the people who can um, you know, work around this are the people with bigger budgets, you know, like there is like that worker. They're huge budgets. But at the end of the day, I think some people who are maybe have a smaller footprint in this kind, you know, and in this state specifically, and then ultimately have a bigger footprint in others, they are not going to want to go through this hurdle. And then when they do not, at the end of the day, who suffers? It's the kids, it's the individuals with autism that we're providing these services to, which is really unfortunate because it's it, we're they're already at a disadvantage. And we're getting them to, you know, we're increasing their quality of life, their family's quality of life, um, working on their development, and just to then abruptly have that stopped, just because they want clinical decisions to be made by clinicians. Well, they already are.

SPEAKER_04 22:42

Yeah, that makes sense. I mean, and I I I would say that even I mean, the common structures that are used, right, is the management service organization structure. And even then, to your point, clinical decisions are still made by clinicians. So you've got the management, you know, the management company deals with the non-clinical side, the administrative side, the practice deals with the you know, the clinical side. So I I wouldn't, you know, the clinic, you know, clinical decisions are still being, you know, done, being done by by the licensees. Um, I will say that you know, there's on that sort of one side, I think you guys are are are kind of you know showcasing sort of the the effects um you know on some of the smaller providers. Um there's you know, I think there are other groups, other stakeholders out there that that believe, you know, corporate ownership of healthcare, whether it's any, I mean, could be any kind of corporate ownership, doesn't have necessarily have to be private equity, but there are other you know uh folks out there that um you know that own and invest in you know healthcare practices that you know they want to maintain that that that um clinical independence. And um and because now BCBAs are being licensed just like the other health professions in Illinois, um you know, they want to they want to essentially require the same model, right? So if you because like again, if you're a medical practice, dental practice, physic you know, physical therapist, whatnot, you you essentially have to use the same um, you know, this this this uh this the same model. Um but I think if we fast forward, so we kind of talked about you know how this this requirement is is um uh you how you've been thinking about this requirement. And it does take place here in um you know January 1st, 2027. There has been some efforts and and part and the main highlight of this you know podcast is is sort of talking through two bills that were proposed uh in Illinois this year. Uh and I think it's due to some of the you know same you know um considerations and same feedback that you both are expressing. Um and those bills kind of do two things. Uh and they're more there's there's more to them, but in my mind it kind of does it does two big things. One, um, it removes this requirement for restructuring. So this requirement that a you know a practice that provides uh you know ABA services needs to be owned by a licensed BCBA. Um and it just outright removes it. Uh and so then that would alleviate uh you know the concerns and the and and the cost of um you know of having to restructure. It also contemplates uh BCBAs, uh you know, licensed behavioral analysts uh owning professional entities. And and and so because essentially what happened, we passed this law that required licensure, passed this law that required restructuring. But then in our professional entity laws, meaning like if you have a professional corporation or a professional uh limited liability company, it doesn't really contemplate licensed behavioral analysts, because that also needed to have been updated. And more specifically, in Illinois law, you can and I call it bundling, like you can group together like professionals in in professional entities, and they can they can operate practices together so long as you comply with certain uh certain requirements. Mainly, you know, if you're bundling um this provider and this provider, you know, they each are responsible for their own profession. You can't have one telling the other what to do. Uh and so this bill would also, or these bills would also um, you know, just account for um, you know, BCBAs, uh, you know, for for license behavioral analysts to be able to have these multidisciplinary um multidisciplinary practices. Now, uh what I've seen, um, and and just uh as a as a quick recap, I mean, we are recording this here at the end of March. Um, and you know, this could change in the future, but uh as of today, March 27th, uh one of the bills, which is Senate Bill 3807, uh is there's actually a deadline today for it to move out of committee. So we'll see where that goes. Uh, and then it has a companion bill, HB 5171, um, that is similar and actually had a hearing this morning, um, both of which are still in place, still active. There's probably going to be more discussions at this point. Um, from what we're hearing, you know, there are there is a um a diverse set of opinions out there from stakeholders, some some for it, some against it. Um, you know, I think you know, sort of balancing some of the things we talked about here today with you know some of the sentiments that I mentioned earlier about, you know, essentially treating uh licensed behavioral analysts the same as other licensed professions in in Illinois, which does have a um you know a very uh established corporate practice, generally, you know, doctrine across the board. Um and so that I think those discussions continue to happen. Um at the I think at the end of the day, both sides want to ensure, like and whatever the result is, I think both sides want to ensure access to care, right? So that we don't have these holes, you know, in areas and cities that don't have providers, right? We want to make sure we've got good quality of care, right? We don't want quality to go down, we want quality to go up always. Um we don't want right costs, right? Costs should be manageable, not astronomical, right? For for families, especially it's your kids. I mean, I've got kids. Like it's it's I you know it's it's it's tough. You've got a lot of expenses. Um totally understand that. Um so I'd be interested to hear, uh, you know, depending on, and we can talk about sort of if if this passes, you know, what does that mean for you? And if this doesn't pass, what does this mean for you? Um, but but I'd be interested to hear uh from both of you sort of um, you know, when when you heard about this happening, did it did, you know, did did it come out of left field for you, or did you, you know, you it was sort of like, oh yeah, this is, you know, this is um I expected this just based on what you were, you know, hear hearing from your colleagues.

SPEAKER_03 29:11

Um I I wasn't expecting this. And like I said, like I don't, I guess, need to worry about it, but I do need to worry about it because I don't have the funds. Like I would have to have someone invest and um so I can like take on all these other kids out there, right? Like right now we can't meet the need that's out there. So to me, it's it did come out of all field. I I'm not happy. Like I to me again, CPOM, I know it's uh it it's it's costly for non-BCBA owners, but to me as a BCBA owner, like it it's still not it's not going to meet the what they're trying to do with it is not going to do at the end of the day. It's kind of how I see it. I just feel like this is like extra steps, and at the end of the day, it just pushes people out. Um, and we don't know how insurance companies will look at it. We don't know if the insurance companies will go in and want to then renegotiate rates with you. Um, the rates in the state are not the best. Um, so you know, quality of like I think uh cost of um living increases constantly. So like that doesn't go up along with that. So I just to me, I um I it, yes, it did come out of the field. Yes, I knew about it when it did pass. I was surprised by it. I'm like, oh well, right now, like that is being done by clinicians. Like the decisions are made by clinicians. So um, and at the end of the day, and I don't know if I'm just gonna say this and it might spark a whole new conversation, you know, we're submitting these treatment plans to insurance companies, and they're the ones that are making those decisions. Like they're the ones that are making the final clinical decisions. So we do, uh, you know, if they're denials, we do appeal them. They have they change their criteria and policies constantly. So we're making sure we're staying on top of proper treatment plans, like at least how they want to see them. Um, quality is there, but at the end of the day, it's really the insurance companies that kind of push back about on the clinical side. Um, so I guess um that was a whole lot of information that I just said. Um with the question you asked, but I just feel like it's not something that's going to um I don't think it's gonna be helpful from my eyes. I don't think it's helpful at all. I really think it's going to harm our industry, um, the industry like of treating individuals with autism, ABA.

SPEAKER_00 31:26

Um I think it's important to mention licensure passed to expand access, right? Prior to licensure, BCBAs had to go through and get supervised by a licensed um practitioner to be able to deliver services for Medicaid uh beneficiaries. But then we were pushing, pushing, pushing for licensure to be a thing because we wanted people on Medicaid to get services. And we didn't intend to have this disruption happen, right? Um, I think we need to go back to the original spirit of licensure and say that we have licensure now, so then more people can get access to services versus we're not trying to control who owns and who doesn't own a company, right? And as Veronica said, me being a non-licensed owner of a small practice, from the beginning of from the day we were formed, I already had a license, uh at the time certified board certified behavior analyst in place to be able to take on that clinical head in the company and manage everything. So then I can just focus fully on the operations. I did my due diligence and I went and I took master's level courses, a lot of them in ABA therapy. So then I can I'm I kind of know a little bit of, but I personally chose not to get licensed because I wanted to focus on the operations, right? I if I were to go and get get licensed as an LBA, things might be a little bit easier for me. But then long term is um I I you know I plan to retire one day. Um there's gonna be a limited pool of people that are able to take on the services and keep the doors open for these children. So it's it's also it's a it's an access question at the end of the day, right? If I want to retire or if I want to move to Europe or I and I need to um start succession planning, I'm limited to a small number of people in the population. First of all, to even be able to afford the fair market value for an organization as at my size, even. Um and and second of all, to be interested to even jump in. Um, so there needs to be options, um, alternative options out there. And I think this is also a concern from licensed practitioners. Okay, sounds great. We're okay with we're already 100% owned by a BCVA, but what happens when I want to retire, right? Yeah.

SPEAKER_04 33:53

I have to go to BA. Yeah, I mean, Krami, it's like, you know, you have you have to do this because you're right, because of, you know, you're not licensed. And so that makes sense. I mean, Veronica, you are licensed, so you don't necessarily have to do it today, but I mean, unless you have other license types that you have to kind of work around. But Veronica, to your point, like if you have to open new locations or you, you know, some of your colleagues shut down and you have to take on their staff and you know, do that. I mean, you can't, again, just snap your fingers and all of a sudden come up with you know all this money to do that. Like, you will have to get investment. Um, I mean, there are limitations to finance. I mean, yes, you can go to a bank, but you probably will have to go and get outside investment, and it's not going to come from another licensed BCBA, you know, so and that investment will have to be in, can't be directly into the, you know, the practice itself. So I I see the tension there. Um, you know, it's almost like you, you know, you you're almost limited on that front with what you can do to you know to try to further um you know growth and and and and and kind of filling some of those access gaps that that may come about from because it's not just changes like this, right? There's other things going on in the world right now that are affecting businesses and you know, prices are going up and you know, uh there's all kinds of you know, stress, I would say, on the market generally that might cause you know your smaller operators to not be in business anymore.

SPEAKER_00 35:29

Yeah. I've I I also want to mention throughout this process, I've considered selling multiple, multiple, multiple times. It's like, can we do it? Yes, no. Can we do it? Yes, no. Because it it's all these um hidden fees behind the restructuring, like that um, for example, we had to get new insurance contracts with the the structure that we set out, right? So then I had to bring on somebody to be able to get us in and then follow up with all these people and be like, hey, set this up, set this up, set this up. And that's a lot of um, first of all, time, like the amount of time that things are taking to actually kick off is is it's not moving in the in the fast enough for me to be able to feel confident and comfortable um at this stage because we're in quarter two and we're getting closer to um the deadline. Um so yeah, I I I did also hear from other colleagues of mine, they are considering selling. Now now they are, right? Because they just simply don't want to deal with it.

SPEAKER_04 36:30

On the on the transition side for payers, curious, there is part of the structuring for that you've experienced so far. Um did you have to hold claims as you restructured, or was there like a period of time where you just didn't get paid, right? Or maybe maybe you lost payment just because of the you know the time differences and sort of the new contracts versus the old contracts, or was that seamless?

SPEAKER_00 36:53

Um it was a brand new entity altogether. So that entity is still inactive technically, um, until we're able to fully set set it up where we had to get a new EMR system. We had to put all our records in in order and make sure that we contract with all these new vendors and all these new partners to be able to continue operating smoothly. And then on top of that, is things change, right? With our current vendors, some of we were locked into a rate three years ago. If I were to recontract them now, we're going, it's going to be even more expensive. So then I had to do more work on finding new partners to work with that we can afford. And then, which means I also have to train all the staff on all these new systems and processes and procedures. And um it all ends up being very, very, very costly aside from a simple filing fee um with IDFPR or um a consultation with an attorney. I met with my attorney like probably 10 hours just last month, just discussing fee structure. How does one entity pay the other? What happens here to make sure that we're we're being fully compliant with all the nuances out there.

SPEAKER_04 38:05

Right. Yeah. And you have to be, I mean, you have to really plan out the payer transition side of things, just because sometimes you can. I mean, I've seen it where people do it quickly and not well informed, not thought out, and then all of a sudden they can't bill anymore, or they have to wait three months to bill, you know, and and that can that can be a you know, closed door, you know, close your door type result if you don't do it correctly.

SPEAKER_03 38:29

So some insurers have a 90-day um policy. So if you don't submit your claims within 90 days, then they you cannot submit your claims afterwards. So like this, it all depends on your insurers. But at the end of the day, to even change like your entity name, let's say, like that still is like you we have contracts that state that we have to inform them by you know a certain time frame. If you're doing anything, um, that is gonna be different from the contract. Um, so I can only imagine what that would look like for someone who has to go in and change all that because it's not that easy. Um, it does you have to almost have you can't have both at the same time, right? Like, so you have to make sure that everything's aligned. Um, like same, I mean, even setting up like your EFTs to go into the right account and it goes into your billing system, like all that has to align properly. Otherwise, then it's just a it's a waste of money of like someone looking. I mean, and at the end of the day, like I'm looking at spreadsheets, right? So, like, how much time am I putting in clinically myself? Like, no, I'm looking at spreadsheets to ensure that we got paid properly, like everything is all aligned, and then we are submitting claims on time, we are checking to ensure that we were paid properly. Like, there's just a whole lot, and it's not it's not an easy process to set all that up to begin with. But then when you're doing it something along the lines of like there's a whole new entity that you're doing it with, then you have kids with authorizations because we have to get prior authorization for all these services. So those authorizations uh they it's not like they just continue. You have to actually call and transfer them if that's going to be an you know an option to transfer them to a new company. But most some of the times you have to start from scratch again. So you have to do an intake and you have to pause, like the child has to be um, their services have to be paused, um, which is like again, same company, different entity name, um, different structure type. So like it will impact it. It's not an easy process. I guess I'm lucky I know how to do it because I had to like do everything from scratch, but it's not an easy process to go through that, even credentialing your staff. Yes, I have it down to a T, but then you'd have to then go and credential with the other entity. And then that that piece of it is like, you know, will they turn that around in time? Um, will you know some of the insurance companies take up to 90 days, to 180 days to be able to credential? So then you have to make sure like who's billing, like ultimately you have to pause things and it it does have an impact on the company and really ultimately the kids, because then they have to pause services so that we're able to get it all right when it's already set up properly.

SPEAKER_00 41:00

I do want to mention really quickly, if we're talking about access, there's two things that come into play. Um, first is Medicaid, right? With and Medicaid credentialing, that is the most difficult administrative burden that I have on my plate day in and day out. Like making sure we follow up with every single person to make sure everything is outlined and things are going in. Things can go in process for like six months, right? That we're not able to operate that way. Um, so with my new entity, I didn't even go forward with Medicaid yet, just because I'm still waiting on a couple um tax documents that they asked me for, but I'm anticipating that's gonna take past January, um, January deadline. So we might have to discharge all our Medicaid kids effective in December, right? Where do they go now? Because I, the new entity that the one that's structured in a way that's compliant with CPOM is not yet in in network. And then those providers are not linked to that entity yet. So then we have to go through provider by provider and put them all in process, and there's going to be all these difficulties along the along the way. So I the a big consideration that my team is making at the moment is do we even want to deal with this? Do we do we want to just find people's services now and let them go and downsize? Or do we want to just push through, push through, push through, but then risk shutting down the business? Because, first of all, we're not adequately funded to begin with, to be even to eat up all those costs. Another piece of it too, since I did a lot of my coursework in a master's program for ABA, I can confidently say coursework and field work supervision that a BCBA candidate has to do, they teach you nothing about credentialing, about payer policy, about corporate compliance, about Medicaid compliance, about any how to employment law, right? They don't teach you any of that. Um, if it Veronica and myself have been in this situation that we've learned along the way, but if we're anticipating that all these LBAs in Illinois are gonna know how to do this and do it properly, this is not it's not the case, right? There's no way.

SPEAKER_04 43:18

Um Yeah, I hear you. Um, you know, obviously you're making the case for an MSO uh indirectly. Um, but look, I mean, it's been in healthcare. Now they're net now it's even for lawyers. Like I don't like dealing with any of the admin stuff. I didn't really learn in law school how to run a business. So I'm kind of, you know, I I I I understand you on that. Um I know you guys have been talking about, I mean, based on your footprint, you know, you were in Illinois. Imagine if you were on the border with Wisconsin, and let's say you had a few clinics in Wisconsin, or let's say you're on the border with northwest Indiana, and you had a few clinics in Indiana, and so and historically, right, you could you could kind of work with in both states, but now Illinois has that requirement. Indiana doesn't, or Wisconsin. Doesn't. And so that is you know for folks that might operate or have practices that are across state lines, especially I mean Illinois, we border like what, like six states or five states, whatever. Like it's a real possibility, right? You've got they could have some really complicated restructuring and issues there. Um, especially that it'll be interesting to see kind of what happens there. But this is this has been a great discussion. I mean, I think we'll see kind of what happens uh with these proposed bills. Um you know, either way, I you know, I think you're seeing both sides of the discussion kind of be very vocal and participating, which is which is generally, you know, I think positive. And and the hope is that there is, you know, something that uh resolves in a way that ultimately you know improves quality and promotes access and um you know hopefully keeps costs down. So we'll we'll kind of see what happens, but appreciate your your you know both of your insights and uh you know good luck to you guys and and thank you for doing great work in our state.

SPEAKER_01 45:06

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