From Chaos Consulting

Poor operations quietly cost your practice money, staff, and growth. Most ABA founders review their monthly profit and loss statements, observe a positive net balance, and assume the infrastructure is sound. That is a critical error. Operational issues rarely manifests as a clean line item in your books labeled as "inefficiency."
Instead, it disguises itself as an RBT resigning after three weeks because their onboarding experience was entirely disorganized. It looks like a billing coordinator quietly adjusting a ninety-day-old claim because the initial authorization lacked a necessary modifier.

In operational engineering, this phenomenon is recognized as the "hidden factory", the redundant, invisible labor required to rectify defects built into a broken process. When a clinic operates on fractured workflows, the payroll effectively funds the same task twice.

Every lapsed insurance authorization, delayed billing cycle, and fragmented training sequence imposes a severe financial penalty.

NC Medicaid just posted a revised draft of Clinical Coverage Policy 8F, straight from their site this time: https://medicaid.ncdhhs.gov/media/16091/download?attachment

What actually changed from the May draft:
• The 97155 telehealth supervision cap moved from 20% to 50% (a real win for access)
• CARS 2 (including CARS2-ST and CARS2-HF) was added as an accepted non provisional diagnostic tool.

What did NOT change, despite what's been circulating:
• The out of state provider restriction is still in the draft. “OOS providers located more than 40 miles from NC's border remain excluded from coverage.” This wasn't removed.

The separate, HB 696 specific statutory ban on BCBA/QASP Medicaid enrollment for out-of-state providers G.S. 108C-9(e) is unaffected by this CCP-8F language either way. That is a Medicaid enrollment rule, this CCP 8F language is a coverage/billing rule.

This is a second, 10day comment period following DHHS revisions from the May to June round. Read the actual super long, ultra boring PDF like I did, before planning around anyone's summary of it, including mine. 🤷🏻‍♀️

medicaid.ncdhhs.gov

Nobody tells you this about running a fractional ops firm: the hardest part isn’t the work. It’s making sure people actually know how to reach you.

So let’s fix that.

Call: 336-390-3751 leave a vm and I will circle back.

Text: 336-390-3751 same number, and honestly the fastest way to reach me.

Email: [email protected] for the longer stuff, sales pitches and the rest.

If you’re an ABA or Mental Health practice owner drowning in operations, a group practice that’s outgrown your systems, or you just have a question about anything, reach out. However works for you.

I’d rather you inquire and find out we’re not a fit than sit on a question because you weren’t sure how to ask it.

I am usually heads down with clients or my team so I don’t live in my email inbox like most. My clients get personal channels to reach me directly as apart of their engagement.

Call. Text. Email. Let’s talk. 🫶🏼

You're leaving so much wasted time on the table with tools you're already paying for.

Everyone wants to jump straight to "we need new software" the second something feels clunky. But most small operations haven't even touched what they already have.

If you're running Microsoft, you're sitting on more automation than you think. Power Automate is already in your subscription. Excel can auto populate, flag, and route things without a single new tool purchase. Outlook rules can sort and forward without a person touching it.

Take intake for example: In a lot of small practices, intake still looks like this: a form comes in, someone manually copies the family's info into a spreadsheet, manually creates a folder, manually adds them to a waitlist tracker, manually follows up in three days if nobody's heard back. That's how many manual touches for one family, repeated every single time someone new comes in the door.

Every one of those steps can trigger the next one automatically. Form submission populates the tracker. Tracker update sends the notification. No response in three days auto flags a personalized follow up. None of that requires new software. It just requires someone sitting down and mapping the workflow once.

And yet, you have a $60k/year staff member still manually typing a name into a spreadsheet. Every single time. A two second task, done a hundred times a week, by someone whose salary reflects a lot more than data entry.

That's not a software problem. That's a "nobody's mapped the process" problem.

Here's the part people don't want to hear: if the reason you haven't fixed this is because you don't want to deal with the work it takes to set it up, that's exactly what I do. I go in build it, set it up and send you on your way after it works. And I train your staff on how to do it, change it and do it again.

Use what you already have to its fullest extent before you spend another dollar on something new. Most of the time buried in your operations is sitting inside tools you're already paying for.

If your ABA practice collapses the moment you take a four-day weekend, you haven’t built a business. You’ve just built a highly volatile job where you are the hostage negotiator.

The most successful practice owners build systems that make their own daily presence entirely optional.

The math is simple: the exact moment a founder steps away from handling daily administrative mishaps and moves into true clinical governance, operational efficiency spikes. True scale requires creating processes, automating your RCM pipeline, and holding your team accountable to clear data.

When your clinic no longer relies on your presence alone to survive the week, you’ve finally built an asset.

Until then, your constant involvement caps your practice's growth.👏

Let’s be honest: You’re currently the highest-paid, least-efficient scheduler at your own company.

Every growing ABA practice hits a point where the founder’s refusal to let go of the steering wheel becomes the leading cause of most operational problems. You didn’t get a BCBA-D just to spend your Tuesdays screaming at insurance portals or trying to decode a 12% claims denial rate.

Data from industry benchmarks shows that administrative backlog takes up to 40% of an ABA practice’s gross revenue when handled by stressed-out clinicians playing the role of COO.

Our embedded operations model parachutes an entire executive back-office into your practice, Fractional COO leadership, RCM/Billing, and Talent Acquisition for less than the cost of one full-time executive hire.

You focus on changing lives and maintaining clinical excellence. We build the infrastructure that stops your cash flow from evaporating.

Stop playing administrator. You’re ruining your own margins.

Let's talk about the RBT pipeline.

RBT to BCBA is the only door most companies show them. Makes sense on paper, RBTs are your billable hours, so the incentive is to keep them delivering direct care. Most places then fast-track the ones who stick around toward the credential that lets them supervise more of it.

But look at what gets skipped entirely: the BCaBA.

It's a real BACB credential. Bachelor's degree, supervised fieldwork, its own exam. It’s a genuine stepping stone between RBT and BCBA, not a consolation prize. Demand for BCaBAs grew 131% last year. That way more than double the growth rate of BCBA demand. The market is asking for this role. Almost nobody's building it.

Here's the part that should really bother you as an owner: BCaBAs aren't just a retention play. They're a billing code most practices are leaving completely on the table.

A BCaBA can bill under their own modifier, at their own rate. It’s not the same as a BCBA, but not RBT level either. There are group and caregiver facing codes they're eligible to deliver too. It is sitting in the same code set every practice already bills against. Most companies never touch any of it, because the role itself was never built. The BCaBA either gets treated as a slightly more expensive RBT, or the credential doesn't exist in the org chart at all.

So you've got a rung on the ladder that: retains people, costs you nothing extra to build, and unlocks revenue you're already authorized to bill but aren't structured to capture.

So what’s the problem? Why aren’t we building this?

If you're only building RBT and BCBA into your model, you're not just capping your clinicians' growth. You're capping your own revenue at the same time.

If you want the actual roadmap, which codes, which modifiers, how to structure the role, that's what I build. DM me and let's talk about what it looks like for your practice.

Every practice owner I talk to assumes cash pay won’t work because “our families are already stretched thin.”

But here’s what I keep finding when I actually pull local rates: parents are already paying for worse.

A special needs babysitter runs about $18-19/hr on the low end. Home care aides run over $22/hr. A week of specialized summer camp for a child with autism can run anywhere from $150 to $1,000+, and that’s before you count the waitlists and the camps that won’t take kids who aren’t independent with toileting.

Parents aren’t comparing your program to free. They’re comparing it to a patchwork of unreliable sitters, waitlisted camps, and missed work days. That’s the real competition and most of it is worse care at a similar or higher price.

And honestly some of this doesn’t even need to be new cash pay revenue. Summer and school breaks are when authorized ABA hours go unused the most. There are hours already approved, already reimbursable, just not structured around the actual school calendar. Audit what you’re already leaving on the table before you build or add to a private pay program.

All of this is ops work. Mapping the billing logic, pricing it against real local rates, building a sliding scale that’s sustainable instead of a guess. It’s not hard, it just needs someone with the bandwidth to lay it out.

There’s so much untapped potential sitting inside practices that never gets built because everyone assumes the math doesn’t work before anyone’s actually run it. Or the classic, the old way of doing ABA works.

Does it? 🤔

Because I still see ALOT of referral chasing.

Your NC telehealth claims aren't getting denied by mistake.

HB 696 is now law (signed April 30, 2026, it's SL 2026-1). If you're running telehealth in North Carolina and wondering why claims are suddenly bouncing, here's what changed:

Out-of-state BCBAs and QASPs can no longer enroll as NC Medicaid providers. Full stop.

In-person assessments are now required with no exceptions for LQASP evaluations.

Paraprofessional telehealth (W/ IN STATE PROVIDER) is restricted unless it falls under a pending DHHS exemption for medical necessity or rural access.

Supervision via telehealth (with an INSTATE PROVIDER) is capped at 50% per client.

This isn't a rumor or a "maybe it'll pass." It's literally statute. What's still being worked out is the operational stuff like how they will audit Telehealth percentages etc. That's the only part still in motion. The rest, already law 🫣

If you've got out-of-state clinicians on staff or you've been leaning on telehealth to cover supervision gaps, this is the moment to audit your model.