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

Episode Transcript
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SPEAKER_02 (00:00):
Welcome to ABA on Tap, where our goal is to find
the best recipe to brew thesmoothest, coldest, and best
tasting ABA around.
I'm Dan Lowry with Mike Rubio,and join us on our journey as we

(00:23):
look back into the ingredientsto form the best concoction of
ABA on tap.
in this podcast we will talkabout the history of the aba
brew how much to consume toachieve the optimum buzz while
not getting too drunk and therecommended pairings to bring to
the table so without further adosit back relax and always

(00:48):
analyze responsibly

SPEAKER_03 (00:55):
all right okay welcome back to yet another
installment of aba on tap i amYour very grateful co-host, Mike
Rubio, along with Mr.
Dan Lowry.
Dan, how you doing, sir?

SPEAKER_02 (01:07):
Doing great.
Feeling very thankful after theholidays, so good times.

SPEAKER_03 (01:12):
Maybe feeling rested.
We've taken a little bit of ahiatus here, and I think we
needed it.
We've taken a few weeks off.

SPEAKER_02 (01:18):
It's been busy.

SPEAKER_03 (01:19):
It's been good to be back in the studio here.
and get things going again.
We are going to continue herelikely our first episode for the
sixth season with yet anotherguest.
We like these guests.
We like people reaching out tous.
We like making connections.
And we've got a really, reallygood resource for you all today.

(01:41):
We've got Suzanne Jeswick.
And she's going to be sharing awhole bunch of resources, which
are actually currently intransformation.
So things we've talked about inthe past, Suzanne, you say are
continually evolving.
So we're very excited to learnmore about that.
So Dan, unless you've gotanything else, I think without
further ado, Suzanne, tell usall about your origin story,

(02:04):
what you do, what you hope todo, and hopefully how ABA on tap
is part of that, thoseprospects.

SPEAKER_00 (02:12):
Oh, great.
Thank you.
This is my first time filming orrecording a podcast.
Oh,

SPEAKER_03 (02:20):
welcome.

SPEAKER_00 (02:21):
Trying to do a new thing.
Trying to be

SPEAKER_03 (02:24):
brave.
We hope it's not your firsttime.
We hope it's only the first timethat you join ABA on tap.
So we'll make it a good episode.

SPEAKER_00 (02:32):
Great.
So I have been a BCBA since2012.
Prior to that, I was a specialed teacher for about five years
in the state of California andactually also in Chicago,
Illinois.
When I was teaching, I met myfirst behavior analyst.
She came into my special edclassroom, which was at that

(02:54):
time like a self-containedautism classroom.
And I just thought everythingshe did was magical.
It was like she was Mary Poppinsand she actually had a British
accent.
She was also from Chicago.
So we got along great.
It was perfect.
But literally, that was my firsttime even knowing what ABA was.

(03:16):
And Taking the, you know, I diddo like a behavior modification
class in my college to become aspecial teacher, but actually
seeing how the science of ABAcan be applied to working with
children in a school setting andall of that was just, like I
said, magical to me at thattime.

(03:37):
What did you see

SPEAKER_02 (03:39):
that was magical?
Like, what did you see actuallyhappen there that you were like,
oh my God, do you remember?
Yeah.

SPEAKER_00 (03:44):
Oh, it was so much.
I mean, she taught us about thefunctions of behavior.
She taught us about how to doantecedent based arrangements to
help or environmentalarrangements to help set the
classroom for success.
Uh, we learned about differentways that the kids can
communicate or to understand wewere using it at the time.

(04:06):
Like she would draw and likehelp the kids to, um, understand
by not just speaking directly tothem.
So like also using othermodalities of communication and,
you know, seeing that like itwould help with some of the kids
who were either not as vocal asothers or non-vocal, like they

(04:31):
could actually communicatetogether with her.
We started using communicationboards.
We had one kid who would typewords to communicate and, And
then, of course, meeting in thisclassroom where we also had to
have behavior plans and thenlike crisis management and just

(04:53):
everything just kind of all camein, fell into place, having her
helping us.
Yeah.
like I said, it was like a nightand day difference in the
classroom.
Like we had a system andeverything was working great.
And, you know, there would bedays where things would like,
maybe somebody had a harder dayat home the night before or

(05:13):
whatever, you know, things wouldalways come up, but we all felt
calm in the moment.
Like we knew what to do.
And that was, it was justperfect.
So.
Yeah.

UNKNOWN (05:27):
Yeah.

SPEAKER_00 (05:28):
So that was, like I said, my first experience or
exposure to ABA or a behavioranalyst.
And back then, she wasn'tactually a certified behavior
analyst.
This was before, what was it,like 2010 or whatever, whenever
the first behavior, first peoplewere getting certified.
I

SPEAKER_03 (05:45):
guess the mandate was in 2012 in California, so
right around the time.

SPEAKER_00 (05:50):
Yeah, but obviously in a school.

SPEAKER_03 (05:52):
Without your board certification prior to that, or
I guess you still can.

SPEAKER_00 (05:58):
Yeah, you still can, depending on who your funding
source is.
Yeah, so I actually burnt outbeing a special ed teacher and
was working at a Starbucks anddoing some other random things,
thinking I was going to become acake decorator and go to
culinary school.
And I was starting to look forother part-time jobs, saw one

(06:18):
for a behavior technician, waslike, gosh, that'll be easy
after the experiences I've hadas a teacher, took the BC job,
started doing it, and justreally fell in love with ABA.
At the time I was working for afairly large company in the
state of California.
And I had, it was a greatexperience.

(06:41):
They did a really fantabulousjob 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 myclient was nine months old,
loved that.
And after about, two to threeyears of doing that just

(07:03):
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 andbecome a BCBI.
That's my origin story.
But I did.
I worked for that company forseven years.
I became a BCBA in 2012.

(07:24):
And in California, like yousaid, the insurance mandate also
came out, I think it was aboutthat year.
So I was in the region that Iwas.
I was one of the first BCBAs totake insurance-funded cases
versus just regional centercases.
And I...
I was navigating having clientsthat were doing like 30-plus

(07:47):
hours a week for the first timeever and just getting used to
what that was going to look likeand then how to write better
reports for insurance.
I was super proud of myself andreally liked to be– I'm going to
say perfect, which is an issue.
Sometimes it's a great thing andsometimes it's not.

(08:10):
So I always started to havethese– really awesome reports
and they would get approved byinsurance.
So I was really proud of myself.
But then I started realizingthat, you know, you can't spend
hours and hours and hourswriting a report.
You have to get faster at it andthings like that.
That's quite an evolution

SPEAKER_03 (08:29):
I think to discuss, right?
I do remember back around 2012working for a company that was I
guess I'm still conducting verytraditional FBAs, very thorough,
but I remember ending up with25, 30 pages on initial reports.
Oh, yeah.
Graphs and everything.

(08:50):
Asking the question, are youserious?
Can anybody get it done withinthe allotted time?
Is this actually a practicalapproach?
Are we able to implement evenhalf of this the way it's
written?
But anyway, maybe we'll get intothat a little more.
You're 100% correct.
Yeah.
yeah

SPEAKER_00 (09:07):
and this was before we had online data collection so
we were still really enteringour data we were still manually
creating graphs and we wereeverything was manually so yeah
i mean the time that it took wasinsane and um at the time my
clinic director we would talkabout this in our clinical

(09:29):
meetings and she was like, well,we used to write reports that
were like a high end steakhouse.
Now we need to write burgersbecause, you know, essentially,
like you said, you just can'tproduce that same quality of
work for, you know, less money,less hours being reimbursed.

SPEAKER_02 (09:49):
That makes a lot of sense.
And I think that's all good ifthat stays to the reports.
My concern is over the last, youknow, 10 or 15 years, that's
also been the mantra of a lot ofpeople'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 tosay lab to living room.
And this, I think, fitsperfectly here.
where I can think back to thistime.
And it was, it was like, we weretrying to replicate these
experimentally laboratorycontrols that we simply didn't
have in somebody's living room.
And I remember saying that evenat that time going like, I

(10:24):
understand that we're trying tostick to a standard and I'm not
opposed to that.
It's just, this is not, we'reliterally missing the mark here.
We're doing way too much work.
It's not necessarily covered bythe funding source.
And again, we're pretending thatwe've got some level of
experimental control by doingthis.
And I just don't think we do.

(10:44):
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 atthe end of the day, we're doing
an applied behavior analysis,we're doing applied work, which
is not gonna look the same asclinical behavior analysis or
any experimental.
So yeah, and then not only that,but if you look at what other

(11:11):
mental health providers, whatthey produce, and then on the
other side of the insurancefunders, if you look at the
medical model, like a speechpath or an OT, their reports are
maybe three to five pages Theydon't have to produce graphs.
They don't have to havesignificant data.
They're using more anecdotalnotes.

(11:32):
And so while our science lovesdata, I get that.
But at the same time, you know,we really shouldn't have to
produce the same amount of workif other mental health providers
don't produce that or if speechpaths 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 thedata while somebody interacts
with the client.
We're expected to do both.
And like Mike, you always talkabout, it's like texting and
driving.
You can do one or the other.
And the more data we take, theless time we actually are
interacting and engaging withthe client.
So therefore, the less efficientour service gets.
So therefore, the more hours weneed to justify the data that

(12:13):
the insurance is requiring thatthey don't want to pay us enough
for because we're requesting somany hours.

SPEAKER_03 (12:19):
Yeah, definitely.
Yeah, it's very challenging.
And again, I don't think any ofus are complaining.
We love our data too.
I think the phrase data drivenis something that gets kicked
around a lot.
And sometimes, quite frankly,we've been data crazy.
Almost producing data points forthe sake of producing data

(12:40):
points, and they don't meananything a lot of the time, at
least not in a truly functionalperspective.
So again, we all agree, nobodyhere is downplaying data.
What we're saying is we're stillevolving as to how to best
capture that data and bestinterpret it toward a good
analysis, toward a fruitfuloutcome.
Anyway,

SPEAKER_02 (13:00):
this is good stuff, guys.
That's always been my concernsince I moved over to Proact.
And I work with a company thatworks not just in the ABA field.
In fact, that's a very smallaspect.
We provide crisis management forpeople with group homes,
hospitals, and stuff like that.
And then they hear we're theBCBAs, and they're like, oh,
you're the data people.
You love data.

(13:21):
And it's like, yeah, we do.
But I also feel like a lot ofPCBs don't even know what to do
with the data.
Yeah, we take a lot of datapoints and we have these graphs,
but like, I can't tell you howmany times, you know, even in my
career, you have these datapoints for every behavior for
every day for months and monthsand months and months.
And then what do we do with it?
It just looks like thisfluctuated data that's like,

(13:42):
yeah, we took it, but do we evenknow 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 Imean, I actually have a lot of
opinions about all of this and Iwould 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 Istarted working as a clinic
director at a startup.
So I was employee number one andI helped write everything from
the employee handbook to theclient handbook to I helped

(14:33):
create all the documents thatpeople needed to sign.
I did hiring and firing.
And I worked there for severalyears before I moved on.
Oh, actually, while I was stillthere, I did a lot of
compliance.
So I did auditing.
I worked with our company tohelp us get into the BHCOE

(14:56):
accreditation.
I also did compliance inrelation to insurance audits.
You did all the fun stuff.
Yeah, I loved it.
Okay.
I was the nerd that wanted to dothat stuff.
So at my core, I lovetechnology.

(15:17):
I love things that are easy to,you know, calculate or figure
out.
And it just kind of rather fitmy personality.
And so I also started fallinginto OBM, started researching
that and taking courses andwebinars in OBM and was like, oh

(15:39):
my gosh, I love process andpolicy development.
I love, like I said, compliance.
And that kind of opened up thedoor for me to take a position
as a regional director foranother company in Chicago,
where I did specifically that.
I was the compliance directorand I, on top of doing clinical

(16:00):
work and managing BCBAs acrossseveral clinics, I also helped
the company to improve theirsystems and everything.
So it was pretty exciting.

SPEAKER_02 (16:14):
Compliance director, did you find it fulfilling to
take your knowledge of the BCBAfield and figure out how to make
that mesh with what insuranceswere asking for?
Is that kind of what What youwere doing?

SPEAKER_00 (16:26):
Yeah, basically that as well as HIPAA and HITECH.
You know, it couldn't beanything from like RBT
compliance.
clients because the RBT hadstarted becoming a thing then.
So yeah, just making sure thatwe had the documentation in
place to, you know, in case wewere to be audited or, you know,

(16:47):
if there was a change withinsurance or a change with like
our billing requirements thatour company aligned with
whatever those changes were.
And so...
It was my job to stay on top ofthat, to stay on top of what was
coming, and then also to helptrain and implement it across
the department for ABA.

(17:10):
Yeah.

SPEAKER_03 (17:10):
Now, as far as the timeline, 2012, you get your
certification.
How many years after that are wetalking now?

SPEAKER_00 (17:19):
Two.
Wow.
So two years after is when Imoved 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 asan 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, anoutside 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 beingthrust in, but back then there
weren't a lot of BCBAs,especially in Illinois.
I think Elaba at that timeprobably had fewer than 300
BCBAs.
I was one of six that did EI orbirth to three in Illinois.

(18:18):
And I did it in three countiesand 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 adifferent time, you know?

SPEAKER_03 (18:33):
All right.
It really, I mean, I'm surewe'll circle back to this, but
it just really speaks to thequick ramp up the very rapid
evolution that we've seen here,which is not necessarily a bad
thing in and of itself, but ithas created the, some challenges
and I know we'll get to thoseand we're actually getting to
some of those already as wetalk.

(18:54):
But yeah, I mean, think aboutthat.
That's, that's 10 years ago thatyou'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 in2012, we were using, I think it
was NPA works for schedulingbilling.
And then we were using back thencatalysts had come out with the
data collection system.
And then in 2014, same, we wereusing Catalyst for data

(19:23):
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 anall-in-one.
And then around 2014, that waswhen we made a whole switch over
to Central Reach for everythingbecause they had started their

(19:45):
all-in-one.
So that's kind of my experiencewas, again, I love technology.
I'm really proficient attechnology.
And most BCBAs aren'tnecessarily.
It's not something that theyhave experience with.
you know, for whatever reason.
And, but like my dad worked forIBM, we had one of the first

(20:09):
computers or like homecomputers, home laptops.
I was just exposed to thatreally early on.
And I worked in computer lab incollege.
I just have always gravitatedtowards that and trying to stay
on top of whatever was comingout at the time.
And so that really like pushedworked well together for me to

(20:33):
fall into that kind ofcompliance role, essentially.
So, you know, when we startedhaving these software platforms
that were cloud-based, I took toit easily.
I could figure out how to createthe forms on the back end so
that BCBAs could use thembecause a lot of that wasn't

(20:54):
like pre-made for you.
You had to hire someone or usesomeone internally to create
them.

SPEAKER_02 (21:01):
Okay.
Yeah, I remember that.
I also remember the Excel datadays when most places didn't
require graphs.
And then I think TRICARE was oneof the first ones that required
graphs, but just for behaviorsfor decrease.
So then we had to move it toExcel from the paper data.
Yeah, I remember that.
Those were the days.
We want to get into, just so wehave enough time to talk about

(21:22):
your project and kind of how youfound us and how we found you.
I'll pass it to you, Mike, ifyou 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 originstory.
You've brought a lot of yourexperience to this.
Quick ramp up in ABA.
I would say your background inspecial ed certainly helped.
Yes.
And maybe we'll talk a littlebit about...
I know that's something that welike to explore, too, in terms
of ABA and how it's practiced inschools.
You had a good experience, itsounds like.

(21:53):
Sometimes it's very difficultfor BCBAs to walk into...
a school setting where a lot ofthe rules are sort of grounded
already.
It's hard to work.
I'm not going to overgeneralizethe statement, but I would say
that in my experience, it's nottypically the place that you're
going to be able to get creativeat.
You're going to have to getcreative at fitting into what

(22:13):
already exists, not necessarilybreaking or reshaping the mold.
So again, I think that thatprobably had a lot of, you know,
gave you a good foundation andthen jump into ABA and you've
brought all your tech experiencenow, sort of a well-rounded
approach to trying to create afull integration tech practice

(22:36):
management, good clinicalpractice and ABA, which is a
really good recipe and it's notalways easy to achieve.

SPEAKER_00 (22:43):
Right.
And yeah, I basically justcontinued in that path where I
still really love technology.
And so now where I'm at is I ownmy own company.
It's called Innovation Moon.
And I'm a solopreneur.

(23:05):
It's just me right now.
I did have an employee last yearas an intern.
But Innovation Moon providesbusiness consultation and
services to ABA businesses.
And so I utilize OBM and I alsoutilize ABA services.

(23:26):
you know, techniques andstrategies.
And then one of the otheraspects of what Innovation Moon
does is I frequently review anddemo technology in the ABA
industry and provide, you know,kind of my like, Like, it's hard

(23:47):
to say.
Like, I provide reviews topeople who are looking to invest
in ABA technology.
I do that through a third party.
And that's been something I'vedone for about three years now
as a side gig.
And I love it.
And people, they're looking forBCBAs to give subject matter

(24:09):
reviews.
you know, an industry levelexperience on like what products
they've used, what platformsthey've used, what they think,
you know, of it, like what'sgood, what's bad.
And that just really, it's a funthing for me to do it on the
side.
So I continue to do that.

(24:29):
I do write reviews and also dolike affiliate marketing for
some of the platforms.
through my blog.
And at some point, I probablywill start doing YouTube
reviews.
I kinda noticed that there'sthis hole, there's a gap.
Right now, business owners orclinical directors, whoever's

(24:50):
the decision maker at an ABAbusiness, there's so many
options now, right?
It used to be that there werethree main players, but now we
have so many more.
And so when you're looking attechnology in the ABA industry,
you know, you have to decide,are you going to do an

(25:10):
all-in-one platform or are yougoing to do, you know, a data
collection and integrate with aCRM or And then what about AI?
Are you going to also add on athird 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 ownercan contact me through
Innovation Moon or even throughLinkedIn if they want to do a
consult.
And I have all this informationabout all the things that are
coming out and what's beingreleased.
And personally, I makesuggestions based off of like

(25:50):
what they're looking for.
What are their pain points?
What size are they?
What is their price point?
And I make clinicalrecommendations to which
platforms they should use.
Right now, most BCBAs or clinicdirectors that are owners,
they're going to Facebook,right?

(26:10):
or LinkedIn groups for businessowners and they're typing in
like, hey, what data collectionplatform do you guys use?
What do you think about thisdata collection platform?
And then you're gonna get likethis mixed reviews, like some
people saying they hate this,don't do that, whatever, but
that's, that's not a lot ofinformation and why do you hate

(26:33):
it?
Right.
You know, or why didn't it workfor you or why does, why do you
love this one?
Is it just the price or is itthe fact that it has a hundred
percent uptime and it integrateswell, like you're not getting
the full picture really.
Yeah.
Yeah.
So that's, I'll go ahead andyou.

SPEAKER_03 (26:55):
I was going to say, so what are some of the trends
you're finding?
What are some of the commonchallenges?
I guess in a nutshell, I love totalk about how as clinicians, we
were probably rather poorlysuited to become business
people.
And I can say that we likelywaited as long as we did for

(27:17):
that reason.
So we had a lot to complainabout in terms of the way our
particular outfits were beingmanaged.
But to be honest, both of usprobably didn't envy those
people in charge either.
And now the more we begin tobuild our business, the more we
realize, yeah, that's what wewere trying to avoid.

(27:37):
This is the pitfall.
This doesn't make any sense.
Give us some common trendsyou're seeing in terms of where
clinicians aren't necessarilythe best capitalists.
And then where, you know, maybethe terrain is changing a little
bit.
What, you know, what your bestadvice thus far would be?

SPEAKER_00 (27:55):
Well, at the end of the day, I would never tell
anyone not to pursue becoming abusiness owner if they're
passionate.
But I would also advise, becauseI do this all the time, I meet
with people who areentrepreneurs.
looking at wanting to starttheir own independent practice
as a BCBA or like we call thatlike a solopreneur, right?

(28:17):
Like they just want to do thebilling and not have any BTs
below them.
And that looks very differentthan owning a clinical ABA
practice where you haveemployees and you are the
business owner and the clinicdirector and the BCBA and doing
all these other hats.

(28:38):
In the first two to three–first, actually, like two to
three years, that's where youmake or break, right?
And in year one, the BCBA isgoing to be just, if they are
the owner, so overwhelmed.
There's so much to do.
And unless you have a lot ofmoney, like some finances or

(29:01):
funding, you can't really hirean extensive admin team.
And so– you're the one who isbilling or you're the one who is
doing the scheduling in themiddle of the night when
so-and-so cancels.
And until you have enough moneyto like support payroll for a
couple months out, you know,like even the thought of hiring

(29:24):
a BCBA can be daunting becauseBCBAs cost so much money.
Yeah.
I think the biggest thing isjust that recognition of you're
going to need money to floatbecause you're not going to be
able to pay yourself for quite awhile.
Because if you have employees,you have to pay them first.
You have to pay your billsfirst.

(29:46):
And if you're not a financeexpert with your own personal
budgeting, you need to have anaccountant to go through and
help you with that.
like financial forecastingessentially.
So you really know what you'regetting into before year one.

SPEAKER_03 (30:05):
Yeah.
I mean, that's quite a prospect.
Again, we're hopefully gettingpast our phase one, right?
We're about a year into this.
We're about a year into this andliterally we're about to start
providing direct service.
So that might be a good way forfolks out there who are

(30:27):
considering this move to thinkabout this.
So 10 months after initiatingour process, getting our
articles of incorporation, youknow, last February.
So the idea that you're going tohire somebody to schedule, to
credential, to do anything,there's nothing coming in.
There's nothing coming in.

(30:47):
I think we've gotten our firstreimbursement 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 theauthorization.
Those those were we're grateful.
We're not we're not being overlyfacetious.
We're very grateful for thatreimbursement.
But I mean, that's 10 monthsfrom 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 youbreak that down.
So there's that initial thoughtprocess of how am I going to
incorporate, how am I going tobecome a business and like all
the pre-planning, like figuringout your name, whatever.
I think that stuff's the funstuff because that's before it

(31:34):
really starts costing you a lotof money, you know?
So it's like your web domain,establishing the business,
whatever.
And I do a training on this forpeople who are interested in
becoming entrepreneurs.
owners.
And then there's the prelaunchphase, which is what you guys
have been in.
It sounds like, so you'vealready done your EIN and then

(31:56):
you went through billing orcredentialing and contracting.
And that's before you, like yousaid, 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, tofloat.

SPEAKER_03 (32:11):
Yeah.

SPEAKER_00 (32:15):
Yeah, so that's probably also part of why like
10 months, it took you thatlong, 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 sixmonths, typically, from your
EIN.
So, you know, like if you canhave money saved up to pay for
like a biller and acredentialer.
So somebody who will like workaround the clock to get you
going faster, maybe three monthsafter your EIN.

(32:46):
But again, you, that meansyou're paying somebody who
already knows how to do it andthey're going to work around the
clock to get it done faster foryou.
So, and that's even doing thedirect service.
And then we all know you're notgoing to get paid from, like one
to two to three months afteryeah so

SPEAKER_03 (33:07):
yeah no that's that's crazy so talking about
the credentialing i mean evenworking together and not
necessarily outsourcing forthose things um one of the
things that we're learning is ifyou if you pay somebody else to
do it then you don't know how todo it yourself and that can be
that into anybody else's dime.

(33:30):
But the idea that it doesbehoove you to sit with those
people, I would say, would youagree?
And learn a little bit aboutthat process where you might
find yourself then always havingto outsource those pieces.

SPEAKER_00 (33:40):
I would say that it depends on the type of business
owner you are or that you wantto be.
If you want to be the personthat does everything, and trust
me, there are aswell-established ABA companies
that the business owner still isdoing everything.
Those business owners burn out.

(34:01):
They get overwhelmed between 60to 80 hours a week for years and
not taking vacation and stilllike trying to do everything.
That's not sustainable.
And then they're going to startlooking for, well, how can I
sell?
And they're not in a place tosell either.
Right.
because they're the one doingeverything.

(34:21):
And so you are, to me, it's amindset of, if you wanna be a
business owner for an ABAtherapy company that, has
employees, you do have to getinto this mindset of, I need to
find people I trust to do thework that I can't do all the

(34:42):
time.
And yes, I think you should haveyour finger on who's doing your
credentialing, who's doing yourcontracting, you should know and
be able to review and make finaldecisions.
But that's a mindset shift,right?
Versus I do everything, I don'ttrust other people.
How do you how do you switch?
I don't trust anyone else to.

(35:03):
And then I burn out and now Idon'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, becauseour impetus, I know a lot of
people, especially privateequity, but just in general, a
lot of people's impetus to getinto the field is profitability,
which is a mindset to have inthe field.
I think ours was.
very different from that was theclinical quality.
And again, not saying that totry to be a martyr.
There are plenty of people thathave similar aspirations, and

(35:34):
then some probably maintain it.
Others probably sell out whenthey get great offers.
But I think that's another partof the mindset that is
important.
It's kind of what is your goalin the field?
What are you trying to achieveand 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 betterbusiness owner, right?
Being a business owner, being aCEO or COO, you're working on
your business, not in it.
And so when we're talking about,you know, your purpose, your

(36:08):
purpose is always your missionand vision.
And you'd have to do what youcan, stick to your values, move
forward through your purpose.
And you should always questionyourself, like, will this...
affect my mission, my vision?
And if it does, then you can, asthe business owner, make a
decision to change and notpursue something else, right?

(36:32):
The other thing I think businessowners need to learn, and
they'll learn it really quickly,is no money, no mission.
So even if your missionstatement or your...
No money, no mission.
So even if your missionstatement is to help improve the
lives of other people, whoeveryour clients are, whatever

(36:54):
application of ABA you'reproviding, if you don't have a
healthy bottom line, you willnot succeed or succeed.
Or last, your company will fail.
You will find yourself at aplace where there isn't money,
like these big offers coming in.
You're going to sell for parts.
You're going to sell for yourBCBAs.

(37:14):
You're going to sell for yourRBTs.
And that's it.
So you need to learn how to be abusiness owner or hire someone
who can do that for you withinyour company.

SPEAKER_03 (37:26):
That is the challenge right there.
And I think you captured it verywell.
One of our main objectives herein preserving clinical quality
is to try and address the stateof the rbt which we think is is
a very important variable inthis whole equation that
sometimes gets i know maybe alittle bit overworked maybe a

(37:48):
little bit mistreated here incalifornia the notion that uh
you could go get more consistenthours and similar pay at
chick-fil-a It doesn't do awhole lot for you.
You went through the Starbuckspiece again, something very
similar, which is, wow, I reallywant to use my degree.
And this is a really good reasonto or place to apply my degree.
And at the same time, I can'tsustain a livelihood doing what

(38:13):
I'm educated on, what my passionis.
That's really, really difficult.
So I know to your point there,that's been our passion.
trying to really address whatwe've seen as a very high
turnover because RBTs aren'tvalued as employees in many
ways.
And we're not trying to becritical or single anybody out.
But the idea that you'recomparing a certain

(38:34):
reimbursement rate to a certainhourly wage, and that's not
working out.
super, that math isn't supergood right now.
Those, you know, thosedifferences 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 Sit really depends on your
reimbursement rate for the, thatposition and for the BCBA
position too, because it used tobe that the money, like

(39:07):
basically your BCBAs would be,uh, Like you would just consider
it a wash, especially if youcouldn't bill concurrently.
Now, most insurances do allowconcurrent billing during
protocol modification and directtreatment combined, but not all
do, we know, right?
And so typically you're losingmoney when a BCBA does work.

(39:31):
That being said, the BCBA has todo the work.
They need to, otherwise we'renot really providing ABA.
So that's not even a question.
You just...
Then you look, okay, well, wheream I making up for this?
Where am I making any type ofrevenue that can turn into
profit?
And in the past, that was easybecause we'd be like, well, the

(39:52):
number of hours the clientsreceive, you know, billed by an
RBT, that's where we're goingto, you know, get some money
because we pay the RBT's lessbecause again, they're, you
know, minimum requirements inmost states, most insurance
companies, it's high schooldegree or equivalent 18 years or
older.

(40:12):
So we're not necessarily, youknow, reimbursed for, to pay
somebody that has a collegedegree to be an RBT.
And that, I mean, there's awhole bunch of other issues.
You know, some states are,you're seeing like, I think in

(40:33):
Florida, it's anywhere from like30 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 Floridabusinesses 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 tonof money.
It's overinflated, oversaturatedarea.
So people will leave one companyto go to the next because
they're offering$5 per hour.

(41:22):
And I agree.
Like I do think RBT should bepaid well, but let's also remind
ourselves that, you know, Atthis time, they don't even have
to have a college degree.
And so we're not, you know, theworkforce that's typically
already in that position issomeone who might be going
through college or, you know,someone who's typically looking

(41:44):
for part time work.
And there are other ways thatyou can provide benefits in a
healthier way.
work environment.
OBM studies this.
Money actually doesn't makepeople stay at a place of
business.

(42:05):
It can be a factor in someonemaking a decision for which
company to work at, but it isn'ta sustaining factor if you end
up taking a job that you hateevery day.
You're going to leave eventuallyanyway.
We need to find better ways toreinforce our employees

SPEAKER_02 (42:25):
that's interesting you brought that up with the
rbts in florida because we justmoderated the conference and
there were some um the what wasthe 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 werelooking at bcba compensation
rates um some companies areoffering more per hour
compensation than ourreimbursement rates are with
insurance how is this even likeIt's not sustainable.
It's just private equity tryingto get in and, and turn it

(42:57):
basically.
And, but which is making themarket really, really
interesting because people arecoming in with these high levels
of, you know, expectation formonetary compensation.
And it's just like, we would gounder 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 itback and say, listen, I mean,
what kind of service are youexpecting 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 needto negotiate for a better
contract rate.
And this is true for every ABAcompany, every single ABA needs
to do this.
And if you can, every state-Beyond having your professional
organization, you need to have acoalition or some kind of group

(43:56):
that can actually do advocacyfor 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 havesomething, reach out to me.
I'll get you in contact withsomebody.
But you need to have a coalitionof ABA providers who all pay
into it, like a professionalorganization.
And that professionalorganization goes to the

(44:21):
insurance, goes to Medicaid, anddoes negotiations as a whole to
get rate increases.
I

SPEAKER_02 (44:27):
love that.
Like ABA, yeah, we need thatbecause it's such a dog-eat-dog
world out there.
Everybody's trying to undercutand When we went to the
insurances, a lot of them werelike, we don't negotiate.
And that's true.
Some of them didn't negotiate.
I think Optum and a couple otherones recently are closing up
their network because they'reoversaturated or say they're

(44:48):
oversaturated.
There is a really interestingjuxtaposition of nine month wait
lists.
How does that work?
UnitedHealthcare, a lot of thesecompanies 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 ofinsurance funding.
This actually leads into I do alot of advocacy work.
Also, I do have an autisticchild and I've been pretty
passionate.
I've done advocacy work as aparent of an autistic child and
I've done advocacy work as theBCBA.

(45:24):
I do both.
I live in Wisconsin, so I'm onthe governor's board for autism,
which is does work with ourmedicaid system um to help you
know improve things i thinkwe're gonna see that it's gonna
continue to be this way for awhile until value-based care

(45:46):
comes out but all small businessowners need to be afraid of
value-based care because thatthat's going to mean they're
going to have to shell out moneyto be able to meet the
standards.
And those standards, you know,every insurance has right now
different standards.
There's no unified standard forwhat they're looking for for

(46:08):
value-based care.
Can you elaborate on what thatis?
Every insurance company isdifferent.
So not all value-based carecompanies You mean elaborate
what value-based care is?
Yeah,

SPEAKER_02 (46:23):
exactly.
Just put that in a nutshell forour audience.

SPEAKER_00 (46:25):
Sure, sure.
So in a nutshell, value-basedcare goes away from the hourly
fee per service or per servicereimbursement to the insurance
company provides a higher valueof money as a contract per
client to And it's per clientreimbursement, essentially, for

(46:49):
their entire service package.
And if you meet, there'sdifferent tiers typically within
value-based care.
So the lowest tier would be likelowest quality provider, and
they get paid the least amountof money.
And then you'll have highertiers.
And then the highest top tierprovider has the highest quality

(47:11):
provider.
and they get paid the most perclient.
So it's not something that'smandated.
It's not something that ishappening everywhere yet, but
there are some states and someinsurance providers that are
moving towards it.
And I think it technically someMedicaid plans as well.

(47:35):
So I think it's Pennsylvaniaright now.
You're kind of seeing likethey're being told that they
have to be, it's eitherPennsylvania or Massachusetts,
one of those states.
They're being mandated that allproviders have to be accredited
through a national accreditationin ABA.
So whether that's ACQ throughCASP, or BHCOE through Jade

(47:58):
Health.
And if they don't have theaccreditation, then they
technically, I don't know ifthey get kicked out of the
network or if they're just goingto get the lowest reimbursement
rates.
So they have one to two years tomove towards accreditation.
And that's what that state'sdoing.
Other states will have, or otherinsurance companies will have

(48:19):
different I sat on Cigna'scommission with the BHCOE as a
provider and a parent to helpgive them input as to how they
should build out theirvalue-based care platform.
And they have so many differentfactors like social validity,
which how many people actuallycapture data on social validity

(48:46):
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, Idon't know, they see it as like,
wait a minute, this, these arekind of loaded questions like
what, where are you going?
Everybody knows what the angleis on it.
And just like doing your violinevery six months and using that
obtuse tool to try to measure.
Everybody knows there's sort ofan angle on this, but we've got

(49:12):
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 asproviders 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 actuallymaking progress to their, to the

(49:38):
typical, you know, Like there'sno comparison, no way to
standardize the data that wehave.
And so, yeah, so value-basedcare, it puts us in a place
where we have to usestandardized assessments to be
able to show outcomes and howare outcomes being measured.

(50:00):
And so if we look at like theVineland, which is, a lot of
insurance companies are alreadyrequiring people to use as a
standardized tool for assessmentevery year.
It's not a great, it doesn'treally tell you much, right?
Like when you look at it withsome

SPEAKER_02 (50:18):
of your- You don't get even good inter-observer
reliability between the RBT andthe fairing.

SPEAKER_03 (50:23):
When it wasn't, in all fairness to the violin, I
think we're all, nobody'strashing it.
It wasn't meant to be thatsensitive.
I don't think.
So

SPEAKER_00 (50:30):
anyway.
No, no.
And it was- meant for thegeneral 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 workedwith um you know the daughter
was 15 years old and had limitedverbal communication vocal
communication and uh had severebehaviors and you know we were

(51:00):
working on basic life skills,like getting dressed
independently and things likethat.
We're following like anafterschool routine to, you
know, put away her items or, youknow, do laundry or whatever.
And like some of the questionsin the Vineland for her age were
like, can she use an electricchainsaw?

(51:20):
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, inorder to have value-based care
platforms or systems and to beable to say who's actually
making progress, they need toutilize multiple sets of
assessments.
And this is where I think it'sgoing to get expensive for small

(51:49):
providers.
Because we've already talkedabout you don't get reimbursed
for the work you do.
So when you're doing reports andassessments.
And so now, instead of justdoing the VB map and maybe like,
if you were like me, I did theVineland and the VB map, or I
would do the Vineland and theAFLs, whatever tools you're

(52:11):
using, you use those because youwere like, okay, well, one is
I'm being told I have to use it.
The other is so that I have someidea of, you know, what skills
to work on in the next, youknow, six months to a year.
Now, throw in, you're going toalso have to do a social
validity assessment with theparents.

(52:34):
Or you're going to have to dosome other kind of assessments
to show, you know, the need orthe necessity for your systems.
And Or for the clinicalrecommendation to be approved,
that costs more money.
And so that's where we're goingto start to see some of the

(52:56):
issues for small providers.
Maybe they don't want to pay foraccreditation because they know
that they're not going to passbecause they don't have all
their policies and procedureswritten out.
Should they?
Yes, 100% they should.
Is it physically possible for aBCBA owner to do everything?
No.
So this is where we're going tostart to see some of that.

(53:18):
making it even harder for oursmall businesses.

SPEAKER_03 (53:24):
And it sounds like accreditation, you know, again,
it's always a challenge to tryand find, to try and strike that
balance between, is this aboutclinical 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 atrue clinician, I always feel
very frustrated at how it endsup being about a lot of
administrative logisticalpieces.
And it's like falling into thatrut with the many companies I've
worked with.
We're gonna have a weeklysupervisor's meeting and it's

(54:03):
gonna be one of two things.
Either you're gonna learnsomething new clinically or
you're gonna have a nice richclinical discussion or you're
gonna spend two hours drudgingover billing and people doing
their conversions, like nothingclinical at all.
I mean, literally as though weknow everything We're as
professionally developed as wecan be.
And now all we have to talkabout is logistics and

(54:27):
administrative procedures.
So would you say theaccreditation process,
unfortunately, is moving in thatdirection?
Or do you find that it's alittle bit more of a balance?

SPEAKER_00 (54:38):
I would say that it's still balanced.
It was balanced when Ipersonally went through it.
There was the operational partof it.
And there was clinical.
And if you go through like, Ithink it's Cigna, like when they
do their audits or Optum maybe,one of them, it's the same

(54:58):
thing.
You have to have someone doingthe operational audit and
someone doing the clinicalaudit.
So I do hope that we continue inthat way so that the clinical is
still very important.
And I think it is equallyimportant to make sure that
we're doing those audits on theclinical operation side because

(55:19):
when we don't that's where yousaw all the fraudulent billing
practices that have been comingout

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 paytheir staff and like you have to
pay your staff like that can'thappen

SPEAKER_02 (55:38):
let me ask you this though um do you think that
policy so yeah we we fortunatelyum that uh purchased a lot of
the handbooks which was veryvery useful uh i mean there's
earthquake policy they're likejust if somebody dies out of the
records yeah there's policiesupon policies upon policies but
let me um ask you um youmentioned the fraudulent billing

(56:02):
do you think that policies havean effect on that because to me
it almost seems like ifsomebody's going to be
fraudulent they'll just putwhatever policy they seem kind
of mutually exclusive what's theHow 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 dointernal audits themselves to
make sure that everything'shappening the way it should.
So it's not just a policy,right?
The policy is the written rule.
And in order for that writtenrule to have any meaning, you
know, just like your driver'shandbook, when you try to become

(56:40):
a driver, a licensed driver,right?
In order for the handbook tohave any meaning, we need to
have procedures in place toreinforce them and to have
consequences when things don'tgo the way they should.
And so if we have policies butwe don't have processes, that's
when you're seeing no one'sactually providing feedback on

(57:03):
is this policy actually inplace, being checked upon, being
reinforced, right?
you know, or like are sayinggoodbye to people that aren't
following the policies.
So, you know, just like dad, youneed to have your finger on your
billing, your contracting.
If you don't have a finger onit, you don't understand it.

(57:23):
Then you need somebody else whodoes 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 likedthat, 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 peoplebilling fraudulently.
I guess one of my concerns isthat it almost seems like in a
lot of these outfits, it's moreof like a top down thing to be
able to maintain those highrates and offer those salaries
and things.
I don't know.
I just can't see how thesereimbursement rates can be
achieved or these salaries canbe achieved with these

(58:02):
reimbursement rates.
Are you not seeing it from, areyou not seeing that, I'm not
saying from that end, excuse me,are you not seeing examples of
almost it being a top-down pieceof fraudulent

SPEAKER_00 (58:13):
billing?
No, I'm not saying that it'snot.
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 AubreyDaniels books, he said, go to
leadership first and then workyour way down.
And you still have to ask thepeople at the lowest level, like
what they're doing, you know,checking and make sure that they

(58:35):
understand every piece of what'srequired of them.
But if leadership isn'tactually, well, that's a bigger
problem.
That's like if the person in thehighest level is the one who's
doing the, uh, the unethicalbilling practices and doing

(58:58):
that, like there isn't a checkand balance until someone from
outside the company comes intoaudit, right?
So that's where you'll see,okay, so your insurance
companies will run audits acouple, every couple of years or
whatever.
And that, you know, that's whenthe, whoever it is that did the

(59:21):
issue, And so, yeah.
Again, I think that's where Iworry for business owners that

(59:44):
rely on themselves doingeverything, especially if
they've never been professionalbillers or they've never been
professional contractors.
But those outside audits come,they'll come from Medicaid.
One of the biggest issues is alot of providers aren't
accepting Medicaid.
So we're not always like that'snot getting accepted.

(01:00:08):
picked up on frequently becauseif you're just not in network,
then it's based off of theindividual insurance company
that, so like, you know, ifyou're in California Magellan or
Anthem Blue Cross or whatever,right, they'll have to run their
own audits to make sure that theinformation that they're getting

(01:00:28):
is correct and that they'rereimbursing you for that.

SPEAKER_02 (01:00:34):
Yeah, no,

SPEAKER_00 (01:00:35):
in California.

SPEAKER_02 (01:00:36):
Oh, sorry, go ahead.

SPEAKER_00 (01:00:38):
Oh, no, it's okay.
I was going to say, if you werecaught, you know, whether,
again, whether it's an issue ofI just didn't know, if you fail
an audit, that's a lot of moneythat you're going to owe back to
the insurance.
And you may even lose thatcontract.
So, you know, depending on howegregious the error was.

SPEAKER_03 (01:01:05):
Hey, this concludes...
part one of our interview withSuzanne Juswick.
Please make sure to tune in forpart two and always analyze
responsibly.
ABA on Tap is recorded live andunfiltered.
We're done for today.
You don't have to go home, butyou can't stay here.
See you next time.

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

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