Starting a business is a scary proposition and often evokes overwhelming questions like:
- Am I ready for this?
- Can I afford this?
- What if I fail?
These questions can be amplified in emerging industries like applied behavior analysis (ABA) where the field itself is on shaky and unstable ground. Being prepared to successfully build an enduring enterprise is critical for those brave ABA souls who endeavor to realize their most passionate projects. Starting a business in a booming field like ABA is promising, especially since demand for services exceeds supply. With customers basically beating down your door, it is easy to see why so many people want to start their ABA business. After all, as the popular quote goes, “Entrepreneurship is living a few years of your life like most people won’t, so that you can spend the rest of your life like most people can’t.”
So, here are some important tips to start an ABA business:
Understand and Follow the Rules: “Hustle isn’t just working on the things you like. It means doing the things you don’t enjoy so you can do the things you love” (Unknown). You know what they don’t teach behavior analysts in graduate school? How to bill insurance companies for ABA services – and for good reason. None of us would have been interested in learning it. However, following funding source guidelines is one of the most important skills an ABA business owner can master. A couple years ago, our field announced standardized billing codes that would—in theory—simplify the medical billing process for all proprietors of ABA services. There’s just one small problem: half of the funding sources and insurance companies have decided to either not adopt those billing codes or have decided to make small (and very impactful) changes to those codes.
So what does that mean for business owners? You need to be extra careful when you and your therapists are billing and when you are providing services. That’s right, billing codes dictate which services you as a board-certified, well-trained, experienced behavior analyst are allowed to provide. So what happens when you don’t follow the rules? In short, funding sources recoup the money. Yes, you understood that correctly – they take the money back, but not quickly and painlessly. You’ll face an excruciatingly painful and stress-inducing audit that can last months and require endless hours answering the same questions over and over again, responding to emails, and sending (and resending) old documents and claims to different departments at the funding source.
Therefore, it is easier to learn and follow the rules, and here are some hints on how to do this right:
- Relationships: Develop and maintain relationships at funding source offices. Once the relationship is established, periodically ask them if you are providing services correctly and ensure that they put their responses in email to document the conversation.
- Funding Source Websites: Regularly check funding source websites and insurance companies that you work with. They often post updates to their provider manuals that will prove valuable to your staff when they are trying to decipher the hieroglyphics that are medical billing codes.
Succession Planning: “Hustle beats talent, when talent doesn’t hustle” (Ross Simmonds). People leave, so get over it and start planning for it. Turnover rates are some of the highest in the human service industry (Bureau of Labor Statistics, 2016) and ABA therapy sits right in the middle of that arena. While proper retention efforts are of the utmost importance, organizational leaders would be negligent if they did not plan for turnover. And succession planning is the first step. Succession planning is simply a process for building a leadership pipeline/talent pool to ensure leadership continuity, developing potential successors in ways that best fit their strengths, identifying the best candidates for categories of positions, and concentrating resources on the talent development process to yield a strong return on investment (Succession Planning Process, 2005). Here are some helpful ways business owners and aspiring entrepreneurs can plan for succession:
- Cross-train your Staff: No, I don’t mean send your employees outside to do pushups on the street. Train your staff to be competent in performing more than one task. The CEO of IDEO, Tim Brown, has come up with a really creative way to describe the difference between staff that are cross-trained and staff that are not. He describes I-shaped individuals as experts in their area who have an extremely limited ability to collaborate across disciplines. T-shaped individuals, on the other hand, have deep expertise in one area and a working understanding across disciplines (Cross Training – Your Best Defense Against Indispensable Employees, 2015). But begin this practice carefully. Cross-training can sometimes give the wrong impression, specifically that you as the business owner are planning to get rid of people, despite all evidence to the contrary. This assumption can evoke disgruntled workplace behavior and create a toxic environment. So, here are a couple tips for creating a positive culture of cross-training:
- Pivot Praise: Reinforce the behavior of those who show interest in learning other tasks in front of others.
- Teamwork: Reinforce teamwork, which fosters learning other skills.
- Scorecards and Evaluations: Make mastering a new skill at work a measure of performance in job evaluations and performance scorecards.
- Regularly Update Job Missions: Creating a mission-based organization is critical for initial success, but not the end of the road when it comes to maintaining success. Ensure that you create job missions that are measurable and aligned with the organization’s mission. And most importantly, regularly update job missions and their associated pinpointed behaviors as they change. That way, in the event of transition, you can hand the information to a new employee and enjoy a smooth changeover.
Money In, Work Out: Bring in money and keep your costs low. I understand this concept sounds like a no-brainer, but this basic business notion holds especially true in the ABA industry. Providing a service in ABA therapy means dealing with cost-sharing and patients who don’t pay on-time. Unfortunately, insurance companies have not yet figured out how to setup cost-sharing for a service that is supposed to be provided several times per week; as a result; they charge co-pays daily and in some cases more than once per day. In short, your aging report is going to be a little messy, so make sure to budget low and stay on top of collections. “The dream is free. The hustle is sold separately” (Unknown).
Here are a few ways to manage your money effectively:
- Use a Practice Management Software System: The federal government provides an EHR incentive program (EHR Incentive Program, 2016) that allots money to health care practices to purchase (or create) software to maintain electronic health records. If this program is offered in your state and for ABA services, use it. Trust me – it will change your business life.
- Job Cost: Job costing is the process of tracking the expenses incurred on a job against the revenue produced by that job (Snyder, 2008). It is absolutely necessary if you want to eventually grow your business. Once you know your per patient cost, you can hire people more efficiently and reduce the possibility of hiring someone you cannot afford.
- Collections: Hire a collections company (or employee) to manage your collections. Not sure if you should hire someone outside of your company to complete admin stuff or hire from within? Check this out: The Pros and Cons of Outsourcing vs. In-House Medical Billing, 2016.
- Share Profits: Create profit-sharing programs and pay for performance systems as opposed to raise and reward systems. In the immortal words of Aubrey Daniels, “there are cheaper ways to make people unhappy” (Bringing Out the Best in People, 2000).
Recruitment: “Without hustle, talent will carry you only so far” (Gary Vaynerchuk). Recruiting talent in ABA is the real challenge. Since there is more ABA work than there are ABA workers, recruitment can be very competitive. Here are some helpful hints for locating eager young talent:
- Establish Partnerships: Create partnerships with universities and offer practicum experiences. This can result in highly motivated and usually very cheap labor, and ensures that many of your therapists will be “homegrown” and stay with your organization throughout their career.
- Crowd Source Recruitment Internally: Create a referral program for your staff that offers recruitment incentives. This can help with retention by incentivizing your staff’s recruitment behavior and bringing in new talent that understands (through their referral) what it means to provide ABA therapy.
Networking: “Some hustle for respect. Some hustle for love, others hustle for truth. We all hustle to survive” (Unknown). In other words, if you struggle with a particular issue, odds are, there is another provider in the same boat. Get to know other providers in your area and communicate as often as possible. The Golden State Warriors’ fans have said it best: “Strength in numbers!” There is going to come a time when you don’t know how to handle a particular situation with a funding source or need to refer a client to an agency you trust. Knowing who to contact makes all the difference. Here are some suggestions on how to develop a network of community partners:
- Events: Organize community provider events and invite colleagues to attend.
- Social Media: Start an online LinkedIn group or email listserv and regularly offer suggestions on how to deal with common problems in the ABA industry.
News Release (Bureau of Labor Statistics). (2016, May 1). Retrieved June 18, 2016, from http://www.bls.gov/news.release/pdf/jolts.pdf
Success Planning Process. (2005, September 1). Retrieved June 19, 2016, from https://www.opm.gov/policy-data-oversight/human-capital-management/reference-materials/leadership-knowledge-management/successionplanning.pdf
Cancialosi, C. (2014, September 15). Cross-Training: Your Best Defense Against Indispensable Employees. Retrieved June 03, 2016, from http://www.forbes.com/ sites/chriscancialosi/2014/ 09/15/ cross-training-your-best-defense-against-indispensable-employees/#33cb7ea86303
EHR Incentive Programs: 2016 Program Requirements. (2016, April 8). Retrieved June 09, 2016, from https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2016ProgramRequirements.html
(2015, January 24). The Pros and Cons of Outsourcing vs. In-House Medical Billing. Retrieved June 16, 2016, from http://billadvocates.com/outsourcing-vs-in-house-medical-billing/
Snyder, S. (2008, January 1). An overview of job costing. Retrieved June 19, 2016, from https://support.office.com/en-us/article/An-overview-of-job-costing-D72B20F1-3771-44A7-80D2-5AC6CB7B9D4A
Daniels, A. C. (2000). Bringing out the best in people: How to apply the astonishing power of positive reinforcement. New York: McGraw-Hill.