As the Trump administration continues to redefine priorities and research around autism, keeping the industry on edge, other pressure points for providers and investors are also mounting in 2025.

Network tightening, payer scrutiny, complexity in authorizations and uncertainty in staffing are creating hurdles for reimbursement negotiations, industry leaders explained at the Autism Investor Summit in April.

“Naturally, as providers, we think about having adversarial relationships with payers. … Sometimes it gets adversarial, but generally, the best path is building relationships with your payers, communicating value, communicating your outcomes and why you are the best in their network,” Jonathan Mueller, founder and Co-CEO of Element RCM and Ascend Behavior Partners, said.

Mueller added, however, that “sometimes it is like an elephant on the chest when it comes to negotiating.”

Denver-based Element RCM is a revenue cycle solutions provider for applied behavior analysis (ABA) providers. Ascend Behavior Partners, also based in Denver, is an in-home ABA therapy provider that serves children with autism.

“Among the few contract negotiations we’ve entered into this year, payers have taken a really, really hard stand on communicating a lot of data and the related outcomes,” Mueller said during AIS.

Although Mueller and his team have received positive feedback when sharing data on its ABA model, diagnostics and family mental health services, that “doesn’t always translate to rate increases,” he noted.

And a flood of ABA providers in the market has also created a need for payers to tighten networks.

“Now we’re seeing very specific pushback on that for all kinds of different reasons, sometimes what feels like spurious ones, but we’ve experienced that directly … ,” Mueller said. “I think there’s going to be more of a reckoning seeing these diverse, low-quality networks. My sense is that payers have to let the dust settle and figure out some quality standards that are to be prioritized over access to treatment.”

Rob Warner, client development executive at Netsmart, agreed.

“That nirvana of access and that quality is still something that a lot of organizations are figuring out,” he explained.

Overland Park, Kansas-based Netsmart is a health care technology provider that offers interoperability and automation solutions for EHRs to help providers track value-based care metrics.

Making the case for reimbursement

A crackdown on fraud, waste and abuse is also driving payers to look at reducing unnecessary costs.

“I think that’s a really important cue that payers will continue to take in the guise of reducing waste, fraud and abuse, which unfortunately means that utilization, potentially reimbursement rates, and a lot more, may also come with reducing that spend,” Mueller said.

Rob Haupt, executive vice president at LEARN Behavioral, echoed this, and noted technology investments can support efficiency in treatment planning and lead to better impact and curb waste.

“Treatment plans are not getting shorter, they’re getting longer, and so the more we can kind of let clinicians be clinicians and spend time with the clients is what I think we all want,” Haupt said.

Baltimore-based LEARN Behavioral is an ABA therapy provider for children with autism. It operates locations in 18 states.

In light of the increased scrutiny, more providers are beginning to play offense when it comes to documentation and compliance to strengthen their case for medical necessity and individualized treatment plans.

“Instead of being reactive and waiting for a claim to be denied because of a documentation rule, or because a compliance piece was missed. Instead, they’re looking for ways to diversify, not only their technology portfolio, but also their payer mix,” Warner said during AIS. “That has been the number one kind of optimization focus: really catching some of those errors upstream with more of those rules and logistics from a configuration standpoint. Then downstream, making sure that bills are getting out the door clean.”

Meanwhile, a growing focus on outcome measurements and pressure to demonstrate clear autism therapy results are slowly moving the needle toward value-based care. Although settling on a clear definition for “outcomes” in autism therapy continues to be a moving target in and of itself.

“I think there are still a lot of conversations about, ultimately, what is an outcome for a child with autism?” Haupt said during AIS. “It’s your perspective as the client, as the parent, as the payer and as the provider that really impacts the definition of an outcome. We’re still not at that point. I think people are looking at outcomes, but that alignment isn’t there just yet.”

Mueller agreed and shared that even working toward accreditation and securing those accolades as an autism service provider doesn’t always count toward proving outcome metrics directly.

“I did have one payer ask me two years ago to show where kiddos’ outcomes improved because of our accreditation,” Mueller said. “And I couldn’t point to it. Again, this is an indirect measure, and it is so tricky.”

Technology and turnover

While some organizations have a multistate presence and can leverage their strategy from one value-based care arrangement and “copy and paste” it to the next, Warner explained, a lot of metrics to support outcomes and value are tied up in siloed systems.

Investing in technology to better support behavioral outcomes tracking and can help translate that into data that payers want and clinicians can utilize.

“We’ve seen a lot of clinical documentation tools come out within the autism space. I think truly coming up with a meaningful workflow that makes sense within the clinician’s day activities – that is something that I still think is not there,” Warner said. “I think there’s a lot of room for improvement on that. But where I see the most room for improvement is in referral management.”

Using technology to support services, free up clinicians’ time and analyze data more effectively may also go a long way to improve staff retention and education, Mueller added. Leveraging AI to make recommendations across treatment plans can ultimately enhance results.

“This technology allows us to look at this child’s program and yeah, it takes a little extra time, maybe to push a button, maybe the user interface takes a little time to learn,” Mueller said. “But those benefits now become clear because they [clinicians] become bought into the idea of why this documentation is needed.”

As high turnover rates among registered behavior technicians (RBTs) and board-certified behavior analysts (BCBAs) continue to be a mounting concern for nearly all autism service providers, demonstrating value through an investment in technology can be paramount to operational adaptation.

“As organizations start to define what they are going to do to really get someone to not only come in the door and be excited, but also want to stay, it is sometimes an investment in your technology,” Mueller said. “Other times, it’s really that look in the mirror at your culture as an organization as well, and really trying to define what makes you special and what makes that team aspect really come together more cohesively.”

High turnover costs organizations thousands of dollars per employee. Indirectly and directly, it can quickly become unsustainable to operate that way, so underscoring clinicians’ value is also key, Haupt agreed.

“Turnover impacts everything. Retention impacts everything,” Haupt said. “The technicians are the ones providing these services every single day. They’re the lifeblood of this service.”

Recognizing that many in the industry do leave positions for an additional bump in pay somewhere else is actually worth a conversation with payer partners – not one to shy away from, he noted.

“I’ve had some payer partners who have actually been really engaged on the turnover conversation. We talked to them about our turnover. We talked to them about our retention,” Haupt said. “I think this is actually one of the things that I found payers wanted to partner more on, not less on.”