Frequently Asked Questions
If my organization was accredited prior to 2021, is my organization held to the new accreditation standards?
If an organization has a signed engagement letter from 2020, they will be evaluated under the 2020 standards, unless they choose to push or reschedule their evaluation.
BHCOE’s expectation is that organizations accredited prior to 2021 work towards compliance with the new standards beginning January 1, 2021 and will be reassessed against those standards at their next evaluation cycle.
If a compliance concern is received about an accredited organization who was accredited prior to 2021, areas of non-compliance with the 2021 standards will be addressed on an individual basis.
How is an accreditation score calculated?
These areas are measured using a variety of sources including qualitative semi-structured interviews with agency leadership, agency staff, and patients, a detailed staff qualification review, document review, staff and patient satisfaction surveys and direct observation of service delivery. Standards are scored based on the information gathered and you are provided with an overall evaluation score.
What are the possible accreditation decisions?
The BHCOE Full Accreditation is valid for one to three years, dependent on the organization’s assessment score. A score of 85-90% reflects a 1-year accreditation, 91-95% reflects a 2-year accreditation and 96-100% reflects a 3-year accreditation.
If an organization scores below 85%, provided they meet all the Must Pass Standards, they will be provided with a Quality Improvement Plan (QIP). The QIP will outline areas for improvement and verification that will be required to demonstrate improvement. Your evaluator can provide support and recommendations for best practice strategies. If you wish to receive coaching, BHCOE can recommend external organizational consultants that can assist with strengthen areas within your practice and with preparation for your re-evaluation.
BHCOE’s Preliminary accreditation is valid for two years. After one year, the cost of the preliminary accreditation may be applied towards the full accreditation in the future.
How are BHCOE standards developed?
The Behavioral Health Center of Excellence Accreditation Program (BHCOE) is required to comply with the essential requirements and policies of ANSI for American National Standards (ANSI) Developers. These requirements are defined in “ANSI Essential Requirements: Due process requirements for American National Standards”. Where the BHCOE Operating Principles and Procedures are silent on an issue, the American National Standards Institute’s (“ANSI”) Essential Requirements document referenced above shall serve as the precedent document.
The BHCOE accreditation process evaluates ABA organizations against standards available via peer reviewed literature, best practice literature and state and federal law. The Code was established by the BHCOE reflect the best practices established by the field of ABA. The Code is comprised of the Preliminary Accreditation Standards and the Full Accreditation Standards. The BHCOE evaluation tool measures Compliance with these Codes.
Codes are developed by the BHCOE Commission. The BHCOE Commission is responsible for developing new or revised language for the Code, as these Codes fall within the scope of these procedures. The BHCOE Commission is organized by the BHCOE Standards Coordinator. Additionally, the BHCOE Standards Coordinator will coordinate Subcommittees, when needed. The BHCOE Commission will maintain and keep current the process, appeals, interpretations, self-assessment guidance and other training and education activities relevant to the Code. The BHCOE Standards Coordinator, BHCOE Commission and Subcommittees must comply with the ANSI requirement for openness, balance and due process.
The BHCOE Commission will also serve as the “consensus body” for the purpose of documenting consensus on all American National Standards proposed by BHCOE.
The Commission is composed of a minimum of ten commissioners who are appointed by BHCOE; Commissioners represent a broad spectrum of public, private and general interest groups.
The ten commissioners represent the following types of organizations.
1. Patient Advocate or Patient Representative (2)
2. Trade Association Representative (1)
3. Private Insurance Representative (1)
4. Public Insurance Representative (1)
5. Academic from Applied Behavior Analysis/field (1)
6. Private sector organizational representative of varying sizes (3)
7. Local State ABA Chapter representative (1)
How much does accreditation cost?
The BHCOE evaluation is like going to the doctor. You pay for the check-up, NOT for the diagnosis. Payment does not impact whether an organization will become a Behavioral Health Center of Excellence. The cost is a flat fee for the evaluation based on the size of the agency and the number of locations. To gain information about the cost for your organization, you may email [email protected] or schedule a call to discuss.
Who completes the evaluation?
How does BHCOE maintain HIPAA compliance?
How does BHCOE maintain HIPAA compliance?
As clinical auditors, we will have access to protected health information (“PHI”) collectively referred to as “HIPAA.” The clinical auditor agrees to fully comply with requirements under HIPAA, throughout the term of the clinical audit. Further, every agent, employee, subsidiary, and affiliate of the Behavioral Health Center of Excellence to whom PHI is received will be required to fully comply with HIPAA, and will be bound by written agreement to the same restrictions and terms and conditions.
Your patients are protected under section 45 CFR 164.506 of the HIPAA Privacy Rule in which:
“Health care operations” are certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support the core functions of treatment and payment. These activities, which are limited to the activities listed in the definition of “health care operations” at 45 CFR 164.501, include:
- Conducting quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, and case management and care coordination;
- Reviewing the competence or qualifications of healthcare professionals, evaluating provider and health plan performance, training health care and non-healthcare professionals, accreditation, certification, licensing, or credentialing activities”
“Health care operations” are certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business and to support the core functions of treatment and payment. These activities, which are limited to the activities listed in the definition of “health care operations” at 45 CFR 164.501, include: Conducting quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, and case management and care coordination; Reviewing the competence or qualifications of health care professionals, evaluating provider and health plan performance, training health care and non-healthcare professionals, accreditation, certification, licensing, or credentialing activities”
In addition, consumers are notified prior to survey administration that the response to the survey is voluntary and will not affect their services in any way. They are also provided with an “opt-out” option at the initial point of contact.
What is the difference between the BACB and BHCOE?
The Behavior Analyst Certification Board® (BACB®) certifies individual behavior-analytic practitioners, whereas BHCOE accredits organizations who may employ those individuals.
Does BHCOE provide any help in preparing for an evaluation?
BHCOE provides ample free resources for organizations to prepare prior to their evaluation. In addition, your assigned evaluator will assist you in understanding the requirements to be in compliance with the standards. BHCOE is not able to provide consultation or coaching services for organizations hoping to pursue accreditation in the future.
Do we have to submit all our programs for accreditation?
Can BHCOE accredit services provided by an individual?
Some payers require preliminary accreditation prior to contracting to provide services. In this case, the BHCOE does accredit an organization who has not yet begun providing services to their clients. This can include individual practitioners, sole proprietors or licensed clinical psychologists. Preliminary accreditation includes a document review and interview and lasts one year. Preliminary accreditation can also be used to prepare for full accreditation.
Why are evaluation interviews recorded?
Recording the evaluation is an important component of BHCOE’s internal quality assurance process. BHCOE regularly conducts inter-observer agreement (IOA) on evaluations to ensure that findings are scored fairly and appropriately. This helps our organization maintain a high standard of reliability in our accreditation scoring process.
What are the financial benefits of BHCOE Accreditation?
1. Liability Reduction: accreditation reduces the risk of allegations of negligence, professional misconduct, and breach of confidentiality — the costs of which can far exceed the cost spent on accreditation.
2. Compliance with Funders: Many funders are moving towards requiring health care providers to hold accreditation for their organization. BHCOE has seen this in some states. Organizations already accredited by BHCOE may be compliant and need not undergo any additional surveys or inspections. In addition, other accreditations are much more expensive. BHCOE is priced as the most affordable accreditation that offers the clinical and administrative practice.
What happens if my organization does not agree with BHCOE's accreditation decision results?
Organizations that the BHCOE has conducted a review of and that have received a Preliminary Accreditation, Full Accreditation, Telehealth Accreditation, Provisional Accreditation or Non-Accreditation may appeal the BHCOE to re-score their accreditation review within 60 days of completion of the debrief call. All documentation is reviewed by an alternate auditor and confirmed by the Appeals Committee. All appeal decisions are final. Click here for the audit rescore form.
How Can I Get Involved?
The Behavioral Health Center of Excellence is looking for community members interested in serving on our Community Advisory Board (CAB). The CAB represents the applied behavior analysis community as clinicians, academics, and ABA agency owners. To learn more, please send your CV to [email protected]