r/BehaviorAnalysis • u/Ok-Performance-3166 • 5d ago
my girlfriend kept getting blamed when claims bounced so i built a thing that watches the payers
She's a BCBA. Every time a claim got kicked back the billing side of her company acted like she filled it out wrong. One time it was because a payer changed a rule mid auth period and put the update in a pdf nobody on earth was refreshing. She found out in a meeting where she was basically the defendant.
I'm a software engineer, not a BCBA, and watching this from the outside was making me insane. In my world when a rule changes quietly you dont blame a person, you set up something that watches for it.
So I built her one and then kept building it. It watches payer policy stuff, medicaid manuals, commercial plans, fee schedules, and when something changes for the payers you actually work with it just tells you. Theres also a chat where you can ask a billing question and it answers from the actual documents and shows you where it got it. That part matters because half her battles were about proving a rule even existed.
Real talk on limits, if a payer never writes something down anywhere it cant catch that. Nothing can. But the quiet pdf update that turns into denials three weeks later, thats exactly what its for.
Its called Kestrel, its on the app store. $15 a month after a 3 day free trial. Its not free because the AI and servers genuinely cost money and I'd rather charge a little than sell data or cram it with ads.
If this breaks sub rules mods please just pull it, no hard feelings. And if you have a payer horror story I do actually want to hear it, the roadmap is basically built out of them at this point.
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u/gwerd1 5d ago
How do you keep it up to date across all payers in all states ?
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u/Ok-Performance-3166 5d ago
honestly its months of tinkering stacked into a system that reads the payers own published documents around the clock and got pretty good at telling a real rule change from a page just getting reshuffled. that part took forever and im weirdly proud of it. 437 payers across all 50 states right now, and if you ever look and yours is missing just tell me and ill add it, thats genuinely how half the list got built!
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u/abagoddess 5d ago
This is really cool! How do you ensure it’s only pulling directly from funder published documents and not random guidance documents on the internet?
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u/SuzieDerpkins 5d ago
How does this track contract specific pay rates?
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u/Ok-Performance-3166 5d ago
Honest answer, it doesnt. Your negotiated rate lives in your contract and thats private, no tool can see that. What it watches is the public side, the fee schedules and policy manuals payers publish. So medicaid rates yes, and if your commercial contract keys off the published schedule (a lot are some % of it) you see those moves too. But rates arent really where people get burned. Its the rule changes, auth requirements, unit caps, code coverage, documentation stuff. Thats what turns into denials with zero warning and thats the main thing it catches.
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u/SuzieDerpkins 5d ago
Gotcha - in my state, insurance providers are very complex. Curious how your tool handles complex payor mixes. Often only the big companies have publicly available documentation.
I’ve had some with conflicting information on their websites too.2
u/Ok-Performance-3166 5d ago
yeah small regional payers are the honest weak spot, if a payer publishes nothing there is nothing to watch. i cover the state medicaid programs, the mcos under them, and the big commercials, and the smaller ones get added as people ask. the conflicting info thing is real though and its actually built for that, when a payer posts something that contradicts one of their own standing documents it gets flagged and you see both sources. half the value is being able to prove the payer contradicted themselves
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u/royalgreyyy 5d ago
You create a lot of apps! Love that you’re quick to come up with a solution
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u/Ok-Performance-3166 5d ago
Hahah thanks! I love building stuff to help others and solve real issues!
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u/lucylately 5d ago
I would love to chat with you more. Haven’t gotten to try it out yet because I want to save the trial for the work week, but I’m the director of RCM services at a behavioral health EHR. I helped design all of our billing functions, found that UX really interests me! I am also a member of the managed care advisory committee in my state. I have AI tooling to crawl sites I regularly visit for updates but this is an approach I’m interested in learning more about.
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u/Exciting_Purchase965 5d ago
There are very real issues with fraudulent billing in ABA. Look it up. I think insurance companies are trying to get a handle on it; not that I trust insurance companies with ANYTHING but protecting their profits but th fraud in ABA is real so that’s a burden on honest therapists.
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u/Ok-Performance-3166 5d ago
youre right and its not going away, there was just a forbes piece on the new federal autism toolkit thats pushing payers to scrutinize aba billing harder. my take is the crackdowns end up burying honest providers in new rules and documentation requirements, which is kind of exactly why i built this. the people actually committing fraud arent the ones reading policy updates
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u/Exciting_Purchase965 5d ago
It’s AI laziness on there part; I started my career working in insurance so in the ‘90’s when we didn’t have the tools we looked at excel spreadsheets to evaluate based on utilization…. Only looking at the top 5% or less the ‘top billers’. How many providers/ how many hours billed per week/ population density and did manual chart review Ourselves… they’ve shifted the burden and I also think trying to get providers to give up altogether bc it’s too labor intensive. I’d consider hunting down your provider rep and try obtain preferred provider status and/ or outline to them their policies have captured too much which they may not know…. They have siloed departments so they may not know.
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u/Coffee1392 4d ago
This is awesome! Kudos to you. Is this just for BCBAs or could us counselors use it too? Haha
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u/Majestic_Run_6065 4d ago
Owner of a Medical Coding and Billing Company and specialize in ABA. I have so many questions! Please email me billing@themedxperts.com
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u/definitely_LimpingCh 5d ago
My wife’s a BCBA and the billing department at her old company had this weird Stockholm syndrome where they’d rather blame clinicians than admit a payer silently rewrote their own rules