🚀 Mastering ABA Business & Technology: Practice Management, Data Collection, & Growth Strategies with Suzanne Juzwik, BCBA | ABA on Tap (Part I)

The field of Applied Behavior Analysis (ABA) is evolving at breakneck speed—from practice management (PM) and data collection software to CRM platforms and value-based care models. To stay ahead, ABA professionals must adapt, innovate, and leverage technology to sustain their businesses.

In this must-listen episode of ABA on Tap, Dan and Mike sit down with Suzanne Juzwik, MA, BCBA—CEO of Innovation Moon and an expert in ABA business operations, EHR software & technology selection, and financial sustainability. Suzanne's journey from special education teacher to ABA tech consultant offers game-changing insights into how BCBAs, RBTs, and ABA business owners can navigate the challenges of reimbursement delays, practice scalability, and operational efficiency.

🔥 What You’ll Learn in This Episode:
✅ The biggest tech mistakes ABA business owners make—and how to fix them
✅ EHR, CRM, and Data Collection Platforms—What’s worth your investment?
✅ Why financial sustainability ("No money, no mission!") is the key to long-term success
✅ The rise of value-based care in ABA and what it means for insurance reimbursements
✅ How to future-proof your practice against emerging industry changes

🚨 New to ABA entrepreneurship? Facing billing, insurance, or operational roadblocks? This episode is packed with actionable advice to help you run a thriving, tech-savvy ABA practice.

🎉 Bonus Announcement: Suzanne Juzwik is officially joining ABA on Tap! As our newest partner, she’ll bring her expertise in business development, marketing, and leadership to help the podcast and our audience grow.

📢 This is Part 1 of a two-part series—don’t miss Part 2, dropping next week!

🎧 Listen now and “Analyze Responsibly”!

👉 Learn more about Suzanne Juzwik & Innovation Moon:
🔗 www.innovationmoon.com

Transcript

SPEAKER_02: 0:00

Welcome to ABA on Tap, where our goal is to find the best recipe to brew the smoothest, coldest, and best tasting ABA around. I'm Dan Lowry with Mike Rubio, and join us on our journey as we look back into the ingredients to form the best concoction of ABA on tap. in this podcast we will talk about the history of the aba brew how much to consume to achieve the optimum buzz while not getting too drunk and the recommended pairings to bring to the table so without further ado sit back relax and always analyze responsibly

SPEAKER_03: 0:55

all right okay welcome back to yet another installment of aba on tap i am Your very grateful co-host, Mike Rubio, along with Mr. Dan Lowry. Dan, how you doing, sir?

SPEAKER_02: 1:07

Doing great. Feeling very thankful after the holidays, so good times.

SPEAKER_03: 1:12

Maybe feeling rested. We've taken a little bit of a hiatus here, and I think we needed it. We've taken a few weeks off.

SPEAKER_02: 1:18

It's been busy.

SPEAKER_03: 1:19

It's been good to be back in the studio here. and get things going again. We are going to continue here likely our first episode for the sixth season with yet another guest. We like these guests. We like people reaching out to us. We like making connections. And we've got a really, really good resource for you all today. We've got Suzanne Jeswick. And she's going to be sharing a whole bunch of resources, which are actually currently in transformation. So things we've talked about in the past, Suzanne, you say are continually evolving. So we're very excited to learn more about that. So Dan, unless you've got anything else, I think without further ado, Suzanne, tell us all about your origin story, what you do, what you hope to do, and hopefully how ABA on tap is part of that, those prospects.

SPEAKER_00: 2:12

Oh, great. Thank you. This is my first time filming or recording a podcast. Oh,

SPEAKER_03: 2:20

welcome.

SPEAKER_00: 2:21

Trying to do a new thing. Trying to be

SPEAKER_03: 2:24

brave. We hope it's not your first time. We hope it's only the first time that you join ABA on tap. So we'll make it a good episode.

SPEAKER_00: 2:32

Great. So I have been a BCBA since 2012. Prior to that, I was a special ed teacher for about five years in the state of California and actually also in Chicago, Illinois. When I was teaching, I met my first behavior analyst. She came into my special ed classroom, which was at that time like a self-contained autism classroom. And I just thought everything she did was magical. It was like she was Mary Poppins and she actually had a British accent. She was also from Chicago. So we got along great. It was perfect. But literally, that was my first time even knowing what ABA was. And Taking the, you know, I did do like a behavior modification class in my college to become a special teacher, but actually seeing how the science of ABA can be applied to working with children in a school setting and all of that was just, like I said, magical to me at that time. What did you see

SPEAKER_02: 3:39

that was magical? Like, what did you see actually happen there that you were like, oh my God, do you remember? Yeah.

SPEAKER_00: 3:44

Oh, it was so much. I mean, she taught us about the functions of behavior. She taught us about how to do antecedent based arrangements to help or environmental arrangements to help set the classroom for success. Uh, we learned about different ways that the kids can communicate or to understand we were using it at the time. Like she would draw and like help the kids to, um, understand by not just speaking directly to them. So like also using other modalities of communication and, you know, seeing that like it would help with some of the kids who were either not as vocal as others or non-vocal, like they could actually communicate together with her. We started using communication boards. We had one kid who would type words to communicate and, And then, of course, meeting in this classroom where we also had to have behavior plans and then like crisis management and just everything just kind of all came in, fell into place, having her helping us. Yeah. like I said, it was like a night and day difference in the classroom. Like we had a system and everything was working great. And, you know, there would be days where things would like, maybe somebody had a harder day at home the night before or whatever, you know, things would always come up, but we all felt calm in the moment. Like we knew what to do. And that was, it was just perfect. So. Yeah.

UNKNOWN: 5:27

Yeah.

SPEAKER_00: 5:28

So that was, like I said, my first experience or exposure to ABA or a behavior analyst. And back then, she wasn't actually a certified behavior analyst. This was before, what was it, like 2010 or whatever, whenever the first behavior, first people were getting certified. I

SPEAKER_03: 5:45

guess the mandate was in 2012 in California, so right around the time.

SPEAKER_00: 5:50

Yeah, but obviously in a school.

SPEAKER_03: 5:52

Without your board certification prior to that, or I guess you still can.

SPEAKER_00: 5:58

Yeah, you still can, depending on who your funding source is. Yeah, so I actually burnt out being a special ed teacher and was working at a Starbucks and doing some other random things, thinking I was going to become a cake decorator and go to culinary school. And I was starting to look for other part-time jobs, saw one for a behavior technician, was like, gosh, that'll be easy after the experiences I've had as a teacher, took the BC job, started doing it, and just really fell in love with ABA. At the time I was working for a fairly large company in the state of California. And I had, it was a great experience. They did a really fantabulous job with like training and like helping us to learn the science, even as behavior technicians. And we got to do birth to three. So that was super fun because my client was nine months old, loved that. And after about, two to three years of doing that just part-time, I finally was like, okay, the cake thing's not going to happen. Why am I fighting this? I need to go to grad school and become a BCBI. That's my origin story. But I did. I worked for that company for seven years. I became a BCBA in 2012. And in California, like you said, the insurance mandate also came out, I think it was about that year. So I was in the region that I was. I was one of the first BCBAs to take insurance-funded cases versus just regional center cases. And I... I was navigating having clients that were doing like 30-plus hours a week for the first time ever and just getting used to what that was going to look like and then how to write better reports for insurance. I was super proud of myself and really liked to be– I'm going to say perfect, which is an issue. Sometimes it's a great thing and sometimes it's not. So I always started to have these– really awesome reports and they would get approved by insurance. So I was really proud of myself. But then I started realizing that, you know, you can't spend hours and hours and hours writing a report. You have to get faster at it and things like that. That's quite an evolution

SPEAKER_03: 8:29

I think to discuss, right? I do remember back around 2012 working for a company that was I guess I'm still conducting very traditional FBAs, very thorough, but I remember ending up with 25, 30 pages on initial reports. Oh, yeah. Graphs and everything. Asking the question, are you serious? Can anybody get it done within the allotted time? Is this actually a practical approach? Are we able to implement even half of this the way it's written? But anyway, maybe we'll get into that a little more. You're 100% correct. Yeah. yeah

SPEAKER_00: 9:07

and this was before we had online data collection so we were still really entering our data we were still manually creating graphs and we were everything was manually so yeah i mean the time that it took was insane and um at the time my clinic director we would talk about this in our clinical meetings and she was like, well, we used to write reports that were like a high end steak house. Now we need to write burgers because, you know, essentially, like you said, you just can't produce that same quality of work for, you know, less money, less hours being reimbursed.

SPEAKER_02: 9:49

That makes a lot of sense. And I think that's all good if that stays to the reports. My concern is over the last, you know, 10 or 15 years, that's also been the mantra of a lot of people's quality of service delivery. And that's the thing. That's

SPEAKER_03: 10:03

a whole other conversation. We like to say here, we like to say lab to living room. And this, I think, fits perfectly here. where I can think back to this time. And it was, it was like, we were trying to replicate these experimentally laboratory controls that we simply didn't have in somebody's living room. And I remember saying that even at that time going like, I understand that we're trying to stick to a standard and I'm not opposed to that. It's just, this is not, we're literally missing the mark here. We're doing way too much work. It's not necessarily covered by the funding source. And again, we're pretending that we've got some level of experimental control by doing this. And I just don't think we do. No, and

SPEAKER_00: 10:47

at the end of the day, you're 100% right, Mike, because it is... what we have to remember is at the end of the day, we're doing an applied behavior analysis, we're doing applied work, which is not gonna look the same as clinical behavior analysis or any experimental. So yeah, and then not only that, but if you look at what other mental health providers, what they produce, and then on the other side of the insurance funders, if you look at the medical model, like a speech path or an OT, their reports are maybe three to five pages They don't have to produce graphs. They don't have to have significant data. They're using more anecdotal notes. And so while our science loves data, I get that. But at the same time, you know, we really shouldn't have to produce the same amount of work if other mental health providers don't produce that or if speech paths and OTs don't. produce that, you know?

SPEAKER_02: 11:51

Especially when we are, it's not like you have an independent observer taking the data while somebody interacts with the client. We're expected to do both. And like Mike, you always talk about, it's like texting and driving. You can do one or the other. And the more data we take, the less time we actually are interacting and engaging with the client. So therefore, the less efficient our service gets. So therefore, the more hours we need to justify the data that the insurance is requiring that they don't want to pay us enough for because we're requesting so many hours.

SPEAKER_03: 12:19

Yeah, definitely. Yeah, it's very challenging. And again, I don't think any of us are complaining. We love our data too. I think the phrase data driven is something that gets kicked around a lot. And sometimes, quite frankly, we've been data crazy. Almost producing data points for the sake of producing data points, and they don't mean anything a lot of the time, at least not in a truly functional perspective. So again, we all agree, nobody here is downplaying data. What we're saying is we're still evolving as to how to best capture that data and best interpret it toward a good analysis, toward a fruitful outcome. Anyway,

SPEAKER_02: 13:00

this is good stuff, guys. That's always been my concern since I moved over to Proact. And I work with a company that works not just in the ABA field. In fact, that's a very small aspect. We provide crisis management for people with group homes, hospitals, and stuff like that. And then they hear we're the BCBAs, and they're like, oh, you're the data people. You love data. And it's like, yeah, we do. But I also feel like a lot of PCBs don't even know what to do with the data. Yeah, we take a lot of data points and we have these graphs, but like, I can't tell you how many times, you know, even in my career, you have these data points for every behavior for every day for months and months and months and months. And then what do we do with it? It just looks like this fluctuated data that's like, yeah, we took it, but do we even know what to do with it? Sorry, I said that's a tangent.

SPEAKER_00: 13:48

That's another big

SPEAKER_03: 13:49

conversation. You got us on the soapbox. Yeah,

SPEAKER_00: 13:52

no, it's okay. I, it's interesting because I mean, I actually have a lot of opinions about all of this and I would love to have a whole nother day to talk about that. But yeah.

SPEAKER_03: 14:06

But you were telling us that you were continuing about your experience. I want to circle back to that. Yeah.

SPEAKER_00: 14:12

Yeah, so since then I moved back to Chicago or Chicagoland suburbs, and then I started working as a clinic director at a startup. So I was employee number one and I helped write everything from the employee handbook to the client handbook to I helped create all the documents that people needed to sign. I did hiring and firing. And I worked there for several years before I moved on. Oh, actually, while I was still there, I did a lot of compliance. So I did auditing. I worked with our company to help us get into the BHCOE accreditation. I also did compliance in relation to insurance audits. You did all the fun stuff. Yeah, I loved it. Okay. I was the nerd that wanted to do that stuff. So at my core, I love technology. I love things that are easy to, you know, calculate or figure out. And it just kind of rather fit my personality. And so I also started falling into OBM, started researching that and taking courses and webinars in OBM and was like, oh my gosh, I love process and policy development. I love, like I said, compliance. And that kind of opened up the door for me to take a position as a regional director for another company in Chicago, where I did specifically that. I was the compliance director and I, on top of doing clinical work and managing BCBAs across several clinics, I also helped the company to improve their systems and everything. So it was pretty exciting.

SPEAKER_02: 16:14

Compliance director, did you find it fulfilling to take your knowledge of the BCBA field and figure out how to make that mesh with what insurances were asking for? Is that kind of what What you were doing?

SPEAKER_00: 16:26

Yeah, basically that as well as HIPAA and HITECH. You know, it couldn't be anything from like RBT compliance. clients because the RBT had started becoming a thing then. So yeah, just making sure that we had the documentation in place to, you know, in case we were to be audited or, you know, if there was a change with insurance or a change with like our billing requirements that our company aligned with whatever those changes were. And so... It was my job to stay on top of that, to stay on top of what was coming, and then also to help train and implement it across the department for ABA. Yeah.

SPEAKER_03: 17:10

Now, as far as the timeline, 2012, you get your certification. How many years after that are we talking now?

SPEAKER_00: 17:19

Two. Wow. So two years after is when I moved to Chicago. I

SPEAKER_03: 17:25

mean, you were a special ed teacher. You paid your dues, if you will.

SPEAKER_00: 17:30

I wasn't a spring chicken, and I did work for seven years in California. So five of those years were as an RBT slash trainee to become a BCPA.

SPEAKER_01: 17:42

At

SPEAKER_00: 17:42

the time, my BCPA was, or actually my person above me wasn't even a BCPA. So I had to hire, you know, an outside BCPA to provide me with field work.

SPEAKER_01: 17:55

Okay. Wow.

SPEAKER_00: 17:57

Yeah. So, I mean, it was kind of being thrust in, but back then there weren't a lot of BCBAs, especially in Illinois. I think Elaba at that time probably had fewer than 300 BCBAs. I was one of six that did EI or birth to three in Illinois. And I did it in three counties and I was the only one that did ABA. Okay.

SPEAKER_01: 18:23

So that

SPEAKER_00: 18:25

includes Chicago and then the North and the West. So there, it just was a different time, you know?

SPEAKER_03: 18:33

All right. It really, I mean, I'm sure we'll circle back to this, but it just really speaks to the quick ramp up the very rapid evolution that we've seen here, which is not necessarily a bad thing in and of itself, but it has created the, some challenges and I know we'll get to those and we're actually getting to some of those already as we talk. But yeah, I mean, think about that. That's, that's 10 years ago that you're, you're describing here. Oh yeah. Yeah. Yeah.

SPEAKER_01: 19:00

Okay.

SPEAKER_00: 19:01

Okay. Yeah. And like I said, I mean, even in 2012, we were using, I think it was NPA works for scheduling billing. And then we were using back then catalysts had come out with the data collection system. And then in 2014, same, we were using Catalyst for data collection and at that time, Central Reach for billing and project management or CRM. And so when you think about it, and this is before they were either of those were an all-in-one. And then around 2014, that was when we made a whole switch over to Central Reach for everything because they had started their all-in-one. So that's kind of my experience was, again, I love technology. I'm really proficient at technology. And most BCBAs aren't necessarily. It's not something that they have experience with. you know, for whatever reason. And, but like my dad worked for IBM, we had one of the first computers or like home computers, home laptops. I was just exposed to that really early on. And I worked in computer lab in college. I just have always gravitated towards that and trying to stay on top of whatever was coming out at the time. And so that really like pushed worked well together for me to fall into that kind of compliance role, essentially. So, you know, when we started having these software platforms that were cloud-based, I took to it easily. I could figure out how to create the forms on the back end so that BCBAs could use them because a lot of that wasn't like pre-made for you. You had to hire someone or use someone internally to create them.

SPEAKER_02: 21:01

Okay. Yeah, I remember that. I also remember the Excel data days when most places didn't require graphs. And then I think TRICARE was one of the first ones that required graphs, but just for behaviors for decrease. So then we had to move it to Excel from the paper data. Yeah, I remember that. Those were the days. We want to get into, just so we have enough time to talk about your project and kind of how you found us and how we found you. I'll pass it to you, Mike, if you have any other questions before we move to the...

SPEAKER_03: 21:30

No, no. I think that's a good place. You've given us your origin story. You've brought a lot of your experience to this. Quick ramp up in ABA. I would say your background in special ed certainly helped. Yes. And maybe we'll talk a little bit about... I know that's something that we like to explore, too, in terms of ABA and how it's practiced in schools. You had a good experience, it sounds like. Sometimes it's very difficult for BCBAs to walk into... a school setting where a lot of the rules are sort of grounded already. It's hard to work. I'm not going to overgeneralize the statement, but I would say that in my experience, it's not typically the place that you're going to be able to get creative at. You're going to have to get creative at fitting into what already exists, not necessarily breaking or reshaping the mold. So again, I think that that probably had a lot of, you know, gave you a good foundation and then jump into ABA and you've brought all your tech experience now, sort of a well-rounded approach to trying to create a full integration tech practice management, good clinical practice and ABA, which is a really good recipe and it's not always easy to achieve.

SPEAKER_00: 22:43

Right. And yeah, I basically just continued in that path where I still really love technology. And so now where I'm at is I own my own company. It's called Innovation Moon. And I'm a solopreneur. It's just me right now. I did have an employee last year as an intern. But Innovation Moon provides business consultation and services to ABA businesses. And so I utilize OBM and I also utilize ABA services. you know, techniques and strategies. And then one of the other aspects of what Innovation Moon does is I frequently review and demo technology in the ABA industry and provide, you know, kind of my like, Like, it's hard to say. Like, I provide reviews to people who are looking to invest in ABA technology. I do that through a third party. And that's been something I've done for about three years now as a side gig. And I love it. And people, they're looking for BCBAs to give subject matter reviews. you know, an industry level experience on like what products they've used, what platforms they've used, what they think, you know, of it, like what's good, what's bad. And that just really, it's a fun thing for me to do it on the side. So I continue to do that. I do write reviews and also do like affiliate marketing for some of the platforms. through my blog. And at some point, I probably will start doing YouTube reviews. I kinda noticed that there's this hole, there's a gap. Right now, business owners or clinical directors, whoever's the decision maker at an ABA business, there's so many options now, right? It used to be that there were three main players, but now we have so many more. And so when you're looking at technology in the ABA industry, you know, you have to decide, are you going to do an all-in-one platform or are you going to do, you know, a data collection and integrate with a CRM or And then what about AI? Are you going to also add on a third platform for that? And so what I do is since I'm

SPEAKER_02: 25:25

in the streets right now trying to figure that out. Absolutely. Go ahead.

SPEAKER_00: 25:29

Yeah. Yeah. And I mean, any business owner can contact me through Innovation Moon or even through LinkedIn if they want to do a consult. And I have all this information about all the things that are coming out and what's being released. And personally, I make suggestions based off of like what they're looking for. What are their pain points? What size are they? What is their price point? And I make clinical recommendations to which platforms they should use. Right now, most BCBAs or clinic directors that are owners, they're going to Facebook, right? or LinkedIn groups for business owners and they're typing in like, hey, what data collection platform do you guys use? What do you think about this data collection platform? And then you're gonna get like this mixed reviews, like some people saying they hate this, don't do that, whatever, but that's, that's not a lot of information and why do you hate it? Right. You know, or why didn't it work for you or why does, why do you love this one? Is it just the price or is it the fact that it has a hundred percent uptime and it integrates well, like you're not getting the full picture really. Yeah. Yeah. So that's, I'll go ahead and you.

SPEAKER_03: 26:55

I was going to say, so what are some of the trends you're finding? What are some of the common challenges? I guess in a nutshell, I love to talk about how as clinicians, we were probably rather poorly suited to become business people. And I can say that we likely waited as long as we did for that reason. So we had a lot to complain about in terms of the way our particular outfits were being managed. But to be honest, both of us probably didn't envy those people in charge either. And now the more we begin to build our business, the more we realize, yeah, that's what we were trying to avoid. This is the pitfall. This doesn't make any sense. Give us some common trends you're seeing in terms of where clinicians aren't necessarily the best capitalists. And then where, you know, maybe the terrain is changing a little bit. What, you know, what your best advice thus far would be?

SPEAKER_00: 27:55

Well, at the end of the day, I would never tell anyone not to pursue becoming a business owner if they're passionate. But I would also advise, because I do this all the time, I meet with people who are entrepreneurs. looking at wanting to start their own independent practice as a BCBA or like we call that like a solopreneur, right? Like they just want to do the billing and not have any BTs below them. And that looks very different than owning a clinical ABA practice where you have employees and you are the business owner and the clinic director and the BCBA and doing all these other hats. In the first two to three– first, actually, like two to three years, that's where you make or break, right? And in year one, the BCBA is going to be just, if they are the owner, so overwhelmed. There's so much to do. And unless you have a lot of money, like some finances or funding, you can't really hire an extensive admin team. And so– you're the one who is billing or you're the one who is doing the scheduling in the middle of the night when so-and-so cancels. And until you have enough money to like support payroll for a couple months out, you know, like even the thought of hiring a BCBA can be daunting because BCBAs cost so much money. Yeah. I think the biggest thing is just that recognition of you're going to need money to float because you're not going to be able to pay yourself for quite a while. Because if you have employees, you have to pay them first. You have to pay your bills first. And if you're not a finance expert with your own personal budgeting, you need to have an accountant to go through and help you with that. like financial forecasting essentially. So you really know what you're getting into before year one.

SPEAKER_03: 30:05

Yeah. I mean, that's quite a prospect. Again, we're hopefully getting past our phase one, right? We're about a year into this. We're about a year into this and literally we're about to start providing direct service. So that might be a good way for folks out there who are considering this move to think about this. So 10 months after initiating our process, getting our articles of incorporation, you know, last February. So the idea that you're going to hire somebody to schedule, to credential, to do anything, there's nothing coming in. There's nothing coming in. I think we've gotten our first reimbursement for, was it two units?

SPEAKER_02: 30:51

Yes, for parent training, because the assessment one got denied.

SPEAKER_03: 30:55

Right,

SPEAKER_02: 30:55

right. The

SPEAKER_03: 30:56

assessment one got denied. The parent training... Hours that were attached to the authorization. Those those were we're grateful. We're not we're not being overly facetious. We're very grateful for that reimbursement. But I mean, that's 10 months from the day we decided to to get this. That's a long time.

SPEAKER_00: 31:13

Well, and and when you talk about that, I mean, that's. there's even parts that you break that down. So there's that initial thought process of how am I going to incorporate, how am I going to become a business and like all the pre-planning, like figuring out your name, whatever. I think that stuff's the fun stuff because that's before it really starts costing you a lot of money, you know? So it's like your web domain, establishing the business, whatever. And I do a training on this for people who are interested in becoming entrepreneurs. owners. And then there's the prelaunch phase, which is what you guys have been in. It sounds like, so you've already done your EIN and then you went through billing or credentialing and contracting. And that's before you, like you said, before you're making any money at all. And depending on the person, like maybe you, I think you guys had other jobs to float your, to float.

SPEAKER_03: 32:11

Yeah.

SPEAKER_00: 32:15

Yeah, so that's probably also part of why like 10 months, it took you that long, it can take less time.

SPEAKER_01: 32:22

But

SPEAKER_00: 32:23

even if you're really aggressive, you're not going to see money before six months, typically, from your EIN. So, you know, like if you can have money saved up to pay for like a biller and a credentialer. So somebody who will like work around the clock to get you going faster, maybe three months after your EIN. But again, you, that means you're paying somebody who already knows how to do it and they're going to work around the clock to get it done faster for you. So, and that's even doing the direct service. And then we all know you're not going to get paid from, like one to two to three months after yeah so

SPEAKER_03: 33:07

yeah no that's that's crazy so talking about the credentialing i mean even working together and not necessarily outsourcing for those things um one of the things that we're learning is if you if you pay somebody else to do it then you don't know how to do it yourself and that can be that into anybody else's dime. But the idea that it does behoove you to sit with those people, I would say, would you agree? And learn a little bit about that process where you might find yourself then always having to outsource those pieces.

SPEAKER_00: 33:40

I would say that it depends on the type of business owner you are or that you want to be. If you want to be the person that does everything, and trust me, there are as well-established ABA companies that the business owner still is doing everything. Those business owners burn out. They get overwhelmed between 60 to 80 hours a week for years and not taking vacation and still like trying to do everything. That's not sustainable. And then they're going to start looking for, well, how can I sell? And they're not in a place to sell either. Right. because they're the one doing everything. And so you are, to me, it's a mindset of, if you wanna be a business owner for an ABA therapy company that, has employees, you do have to get into this mindset of, I need to find people I trust to do the work that I can't do all the time. And yes, I think you should have your finger on who's doing your credentialing, who's doing your contracting, you should know and be able to review and make final decisions. But that's a mindset shift, right? Versus I do everything, I don't trust other people. How do you how do you switch? I don't trust anyone else to. And then I burn out and now I don't know how to train anyone else how to do it.

SPEAKER_02: 35:08

Yeah. Yeah.

SPEAKER_03: 35:10

That's really good advice.

SPEAKER_02: 35:11

That's really good advice. That's important, too, because our impetus, I know a lot of people, especially private equity, but just in general, a lot of people's impetus to get into the field is profitability, which is a mindset to have in the field. I think ours was. very different from that was the clinical quality. And again, not saying that to try to be a martyr. There are plenty of people that have similar aspirations, and then some probably maintain it. Others probably sell out when they get great offers. But I think that's another part of the mindset that is important. It's kind of what is your goal in the field? What are you trying to achieve and accomplish?

SPEAKER_01: 35:46

Oh,

SPEAKER_02: 35:46

100%.

SPEAKER_00: 35:47

But I would say you can still get clinical quality and learn how to be a better business owner, right? Being a business owner, being a CEO or COO, you're working on your business, not in it. And so when we're talking about, you know, your purpose, your purpose is always your mission and vision. And you'd have to do what you can, stick to your values, move forward through your purpose. And you should always question yourself, like, will this... affect my mission, my vision? And if it does, then you can, as the business owner, make a decision to change and not pursue something else, right? The other thing I think business owners need to learn, and they'll learn it really quickly, is no money, no mission. So even if your mission statement or your... No money, no mission. So even if your mission statement is to help improve the lives of other people, whoever your clients are, whatever application of ABA you're providing, if you don't have a healthy bottom line, you will not succeed or succeed. Or last, your company will fail. You will find yourself at a place where there isn't money, like these big offers coming in. You're going to sell for parts. You're going to sell for your BCBAs. You're going to sell for your RBTs. And that's it. So you need to learn how to be a business owner or hire someone who can do that for you within your company.

SPEAKER_03: 37:26

That is the challenge right there. And I think you captured it very well. One of our main objectives here in preserving clinical quality is to try and address the state of the rbt which we think is is a very important variable in this whole equation that sometimes gets i know maybe a little bit overworked maybe a little bit mistreated here in california the notion that uh you could go get more consistent hours and similar pay at chick-fil-a It doesn't do a whole lot for you. You went through the Starbucks piece again, something very similar, which is, wow, I really want to use my degree. And this is a really good reason to or place to apply my degree. And at the same time, I can't sustain a livelihood doing what I'm educated on, what my passion is. That's really, really difficult. So I know to your point there, that's been our passion. trying to really address what we've seen as a very high turnover because RBTs aren't valued as employees in many ways. And we're not trying to be critical or single anybody out. But the idea that you're comparing a certain reimbursement rate to a certain hourly wage, and that's not working out. super, that math isn't super good right now. Those, you know, those differences in California. Yeah.

SPEAKER_00: 38:46

And in some states it's really overflated. So one of the things that I, because I work with business owners across, you know, the U S it really depends on your reimbursement rate for the, that position and for the BCBA position too, because it used to be that the money, like basically your BCBAs would be, uh, Like you would just consider it a wash, especially if you couldn't bill concurrently. Now, most insurances do allow concurrent billing during protocol modification and direct treatment combined, but not all do, we know, right? And so typically you're losing money when a BCBA does work. That being said, the BCBA has to do the work. They need to, otherwise we're not really providing ABA. So that's not even a question. You just... Then you look, okay, well, where am I making up for this? Where am I making any type of revenue that can turn into profit? And in the past, that was easy because we'd be like, well, the number of hours the clients receive, you know, billed by an RBT, that's where we're going to, you know, get some money because we pay the RBT's less because again, they're, you know, minimum requirements in most states, most insurance companies, it's high school degree or equivalent 18 years or older. So we're not necessarily, you know, reimbursed for, to pay somebody that has a college degree to be an RBT. And that, I mean, there's a whole bunch of other issues. You know, some states are, you're seeing like, I think in Florida, it's anywhere from like 30 to 40,$45 an hour for an RBT. Yet the reimbursement rates are, you know, only a couple dollars more than that. for RBT with Medicaid. I don't know how Florida businesses are doing it, to be honest with you. And that's Medicaid.

SPEAKER_02: 40:56

You're saying that's what they're getting paid?

SPEAKER_00: 41:02

Yeah, RBT's. You'll see maybe the lowest 25, but there are competitors who are offering bonuses and a ton of money. It's overinflated, oversaturated area. So people will leave one company to go to the next because they're offering$5 per hour. And I agree. Like I do think RBT should be paid well, but let's also remind ourselves that, you know, At this time, they don't even have to have a college degree. And so we're not, you know, the workforce that's typically already in that position is someone who might be going through college or, you know, someone who's typically looking for part time work. And there are other ways that you can provide benefits in a healthier way. work environment. OBM studies this. Money actually doesn't make people stay at a place of business. It can be a factor in someone making a decision for which company to work at, but it isn't a sustaining factor if you end up taking a job that you hate every day. You're going to leave eventually anyway. We need to find better ways to reinforce our employees

SPEAKER_02: 42:25

that's interesting you brought that up with the rbts in florida because we just moderated the conference and there were some um the what was the name of the conference why am i drawn to blackboard

SPEAKER_03: 42:34

uh cpaba

SPEAKER_02: 42:35

yeah um and you know they were talking about it we'd run into this too when we were looking at bcba compensation rates um some companies are offering more per hour compensation than our reimbursement rates are with insurance how is this even like It's not sustainable. It's just private equity trying to get in and, and turn it basically. And, but which is making the market really, really interesting because people are coming in with these high levels of, you know, expectation for monetary compensation. And it's just like, we would go under if we offered you, it's now we're trying to be mean.

SPEAKER_00: 43:11

Oh, a hundred percent.

SPEAKER_02: 43:13

Some of the,

SPEAKER_03: 43:14

some of the initial contracts we got, some of the initial rates that we received. And we, we, We had to kick it back and say, listen, I mean, what kind of service are you expecting us to provide? You want clinical quality, right? We can't do it at this rate. It doesn't work. It would have to be-

SPEAKER_00: 43:32

And that's what you need to do. You need to say no, or you need to negotiate for a better contract rate. And this is true for every ABA company, every single ABA needs to do this. And if you can, every state- Beyond having your professional organization, you need to have a coalition or some kind of group that can actually do advocacy for your

SPEAKER_01: 43:59

state

SPEAKER_00: 44:01

with your large insurance companies together. improve the reimbursement rates. So if your state doesn't have something, reach out to me. I'll get you in contact with somebody. But you need to have a coalition of ABA providers who all pay into it, like a professional organization. And that professional organization goes to the insurance, goes to Medicaid, and does negotiations as a whole to get rate increases. I

SPEAKER_02: 44:27

love that. Like ABA, yeah, we need that because it's such a dog-eat-dog world out there. Everybody's trying to undercut and When we went to the insurances, a lot of them were like, we don't negotiate. And that's true. Some of them didn't negotiate. I think Optum and a couple other ones recently are closing up their network because they're oversaturated or say they're oversaturated. There is a really interesting juxtaposition of nine month wait lists. How does that work? UnitedHealthcare, a lot of these companies closing down and saying they don't need services. It's very interesting.

SPEAKER_00: 45:02

I mean, that's been happening since the beginning and I will the beginning of insurance funding. This actually leads into I do a lot of advocacy work. Also, I do have an autistic child and I've been pretty passionate. I've done advocacy work as a parent of an autistic child and I've done advocacy work as the BCBA. I do both. I live in Wisconsin, so I'm on the governor's board for autism, which is does work with our medicaid system um to help you know improve things i think we're gonna see that it's gonna continue to be this way for a while until value-based care comes out but all small business owners need to be afraid of value-based care because that that's going to mean they're going to have to shell out money to be able to meet the standards. And those standards, you know, every insurance has right now different standards. There's no unified standard for what they're looking for for value-based care. Can you elaborate on what that is? Every insurance company is different. So not all value-based care companies You mean elaborate what value-based care is? Yeah,

SPEAKER_02: 46:23

exactly. Just put that in a nutshell for our audience.

SPEAKER_00: 46:25

Sure, sure. So in a nutshell, value-based care goes away from the hourly fee per service or per service reimbursement to the insurance company provides a higher value of money as a contract per client to And it's per client reimbursement, essentially, for their entire service package. And if you meet, there's different tiers typically within value-based care. So the lowest tier would be like lowest quality provider, and they get paid the least amount of money. And then you'll have higher tiers. And then the highest top tier provider has the highest quality provider. and they get paid the most per client. So it's not something that's mandated. It's not something that is happening everywhere yet, but there are some states and some insurance providers that are moving towards it. And I think it technically some Medicaid plans as well. So I think it's Pennsylvania right now. You're kind of seeing like they're being told that they have to be, it's either Pennsylvania or Massachusetts, one of those states. They're being mandated that all providers have to be accredited through a national accreditation in ABA. So whether that's ACQ through CASP, or BHCOE through Jade Health. And if they don't have the accreditation, then they technically, I don't know if they get kicked out of the network or if they're just going to get the lowest reimbursement rates. So they have one to two years to move towards accreditation. And that's what that state's doing. Other states will have, or other insurance companies will have different I sat on Cigna's commission with the BHCOE as a provider and a parent to help give them input as to how they should build out their value-based care platform. And they have so many different factors like social validity, which how many people actually capture data on social validity for their clients right now, right? So, and granted,

SPEAKER_03: 48:51

we've tried to actually necessarily want to answer those things or they, I don't know, they see it as like, wait a minute, this, these are kind of loaded questions like what, where are you going? Everybody knows what the angle is on it. And just like doing your violin every six months and using that obtuse tool to try to measure. Everybody knows there's sort of an angle on this, but we've got to do it. So anyway.

SPEAKER_00: 49:13

Well, and also going back to when we talk about data, all the data that we as providers have been collecting for years is single study, right? Single client. And so at the end of the day, there's almost been no way to compare like who's actually making progress to their, to the typical, you know, Like there's no comparison, no way to standardize the data that we have. And so, yeah, so value-based care, it puts us in a place where we have to use standardized assessments to be able to show outcomes and how are outcomes being measured. And so if we look at like the Vineland, which is, a lot of insurance companies are already requiring people to use as a standardized tool for assessment every year. It's not a great, it doesn't really tell you much, right? Like when you look at it with some

SPEAKER_02: 50:18

of your- You don't get even good inter-observer reliability between the RBT and the fairing.

SPEAKER_03: 50:23

When it wasn't, in all fairness to the violin, I think we're all, nobody's trashing it. It wasn't meant to be that sensitive. I don't think. So

SPEAKER_00: 50:30

anyway. No, no. And it was- meant for the general population that's why it's a standardized

SPEAKER_03: 50:36

assessment really good point absolutely

SPEAKER_00: 50:38

so when i would do it and i i had um my last clients that i personally worked with um you know the daughter was 15 years old and had limited verbal communication vocal communication and uh had severe behaviors and you know we were working on basic life skills, like getting dressed independently and things like that. We're following like an afterschool routine to, you know, put away her items or, you know, do laundry or whatever. And like some of the questions in the Vineland for her age were like, can she use an electric chainsaw? Like power tools. I'm like, ah, good God. No.

SPEAKER_01: 51:27

Yeah. Yeah.

SPEAKER_00: 51:29

It's just funny. But at the end of the day, in order to have value-based care platforms or systems and to be able to say who's actually making progress, they need to utilize multiple sets of assessments. And this is where I think it's going to get expensive for small providers. Because we've already talked about you don't get reimbursed for the work you do. So when you're doing reports and assessments. And so now, instead of just doing the VB map and maybe like, if you were like me, I did the Vineland and the VB map, or I would do the Vineland and the AFLs, whatever tools you're using, you use those because you were like, okay, well, one is I'm being told I have to use it. The other is so that I have some idea of, you know, what skills to work on in the next, you know, six months to a year. Now, throw in, you're going to also have to do a social validity assessment with the parents. Or you're going to have to do some other kind of assessments to show, you know, the need or the necessity for your systems. And Or for the clinical recommendation to be approved, that costs more money. And so that's where we're going to start to see some of the issues for small providers. Maybe they don't want to pay for accreditation because they know that they're not going to pass because they don't have all their policies and procedures written out. Should they? Yes, 100% they should. Is it physically possible for a BCBA owner to do everything? No. So this is where we're going to start to see some of that. making it even harder for our small businesses.

SPEAKER_03: 53:24

And it sounds like accreditation, you know, again, it's always a challenge to try and find, to try and strike that balance between, is this about clinical quality or is this now about administrative prowess, which you need both.

SPEAKER_01: 53:39

It's both, yeah.

SPEAKER_03: 53:40

good procedures and policies, but I always, I mean, again, speaking, spoken like a true clinician, I always feel very frustrated at how it ends up being about a lot of administrative logistical pieces. And it's like falling into that rut with the many companies I've worked with. We're gonna have a weekly supervisor's meeting and it's gonna be one of two things. Either you're gonna learn something new clinically or you're gonna have a nice rich clinical discussion or you're gonna spend two hours drudging over billing and people doing their conversions, like nothing clinical at all. I mean, literally as though we know everything We're as professionally developed as we can be. And now all we have to talk about is logistics and administrative procedures. So would you say the accreditation process, unfortunately, is moving in that direction? Or do you find that it's a little bit more of a balance?

SPEAKER_00: 54:38

I would say that it's still balanced. It was balanced when I personally went through it. There was the operational part of it. And there was clinical. And if you go through like, I think it's Cigna, like when they do their audits or Optum maybe, one of them, it's the same thing. You have to have someone doing the operational audit and someone doing the clinical audit. So I do hope that we continue in that way so that the clinical is still very important. And I think it is equally important to make sure that we're doing those audits on the clinical operation side because when we don't that's where you saw all the fraudulent billing practices that have been coming out

SPEAKER_03: 55:25

excellent

SPEAKER_00: 55:26

right

SPEAKER_03: 55:27

and

SPEAKER_00: 55:28

or just you know i there would there would be companies that like wouldn't pay their staff and like you have to pay your staff like that can't happen

SPEAKER_02: 55:38

let me ask you this though um do you think that policy so yeah we we fortunately um that uh purchased a lot of the handbooks which was very very useful uh i mean there's earthquake policy they're like just if somebody dies out of the records yeah there's policies upon policies upon policies but let me um ask you um you mentioned the fraudulent billing do you think that policies have an effect on that because to me it almost seems like if somebody's going to be fraudulent they'll just put whatever policy they seem kind of mutually exclusive what's the How do you bring those two things together?

SPEAKER_00: 56:17

Well, at the end of the day, that should be through audits. So whether the company should do internal audits themselves to make sure that everything's happening the way it should. So it's not just a policy, right? The policy is the written rule. And in order for that written rule to have any meaning, you know, just like your driver's handbook, when you try to become a driver, a licensed driver, right? In order for the handbook to have any meaning, we need to have procedures in place to reinforce them and to have consequences when things don't go the way they should. And so if we have policies but we don't have processes, that's when you're seeing no one's actually providing feedback on is this policy actually in place, being checked upon, being reinforced, right? you know, or like are saying goodbye to people that aren't following the policies. So, you know, just like dad, you need to have your finger on your billing, your contracting. If you don't have a finger on it, you don't understand it. Then you need somebody else who does understand it to also do that audit. Right.

SPEAKER_02: 57:30

So I think you're coming from the perspective, which makes it, I really liked that, you know, policies are nothing without procedures. I I'm a steal that line.

UNKNOWN: 57:39

Yeah.

SPEAKER_02: 57:39

That's coming from the idea that it's kind of a bottom up piece of people billing fraudulently. I guess one of my concerns is that it almost seems like in a lot of these outfits, it's more of like a top down thing to be able to maintain those high rates and offer those salaries and things. I don't know. I just can't see how these reimbursement rates can be achieved or these salaries can be achieved with these reimbursement rates. Are you not seeing it from, are you not seeing that, I'm not saying from that end, excuse me, are you not seeing examples of almost it being a top-down piece of fraudulent

SPEAKER_00: 58:13

billing? No, I'm not saying that it's not. It can definitely be a top-down. I mean, at the end of the day, most things are top-down. if you read any of Aubrey Daniels books, he said, go to leadership first and then work your way down. And you still have to ask the people at the lowest level, like what they're doing, you know, checking and make sure that they understand every piece of what's required of them. But if leadership isn't actually, well, that's a bigger problem. That's like if the person in the highest level is the one who's doing the, uh, the unethical billing practices and doing that, like there isn't a check and balance until someone from outside the company comes into audit, right? So that's where you'll see, okay, so your insurance companies will run audits a couple, every couple of years or whatever. And that, you know, that's when the, whoever it is that did the issue, And so, yeah. Again, I think that's where I worry for business owners that rely on themselves doing everything, especially if they've never been professional billers or they've never been professional contractors. But those outside audits come, they'll come from Medicaid. One of the biggest issues is a lot of providers aren't accepting Medicaid. So we're not always like that's not getting accepted. picked up on frequently because if you're just not in network, then it's based off of the individual insurance company that, so like, you know, if you're in California Magellan or Anthem Blue Cross or whatever, right, they'll have to run their own audits to make sure that the information that they're getting is correct and that they're reimbursing you for that.

SPEAKER_02: 1:00:34

Yeah, no,

SPEAKER_00: 1:00:35

in California.

SPEAKER_02: 1:00:36

Oh, sorry, go ahead.

SPEAKER_00: 1:00:38

Oh, no, it's okay. I was going to say, if you were caught, you know, whether, again, whether it's an issue of I just didn't know, if you fail an audit, that's a lot of money that you're going to owe back to the insurance. And you may even lose that contract. So, you know, depending on how egregious the error was.

SPEAKER_03: 1:01:05

Hey, this concludes... part one of our interview with Suzanne Juswick. Please make sure to tune in for part two and always analyze responsibly. ABA on Tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.