The Impact of Medicare on Private Health Plans Reimbursement for Speech-Language Pathology Services and Devices Features
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Features  |   July 01, 2003
The Impact of Medicare on Private Health Plans
Author Notes
  • Patricia Ourand, is the president of Associated Speech & Language Services, Inc., a speech-language pathology practice serving the Baltimore/ Washington area. She specializes in augmentative and alternative communication, and works with private health plans in the role of consultant and reviewer.
    Patricia Ourand, is the president of Associated Speech & Language Services, Inc., a speech-language pathology practice serving the Baltimore/ Washington area. She specializes in augmentative and alternative communication, and works with private health plans in the role of consultant and reviewer.×
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Speech, Voice & Prosodic Disorders / Practice Management / Features
Features   |   July 01, 2003
The Impact of Medicare on Private Health Plans
The ASHA Leader, July 2003, Vol. 8, 8-13. doi:10.1044/leader.FTR2.08132003.4
The ASHA Leader, July 2003, Vol. 8, 8-13. doi:10.1044/leader.FTR2.08132003.4
Mr. Smith walks into your office with a referral for a speech-language evaluation because of communication problems related to a stroke. The service is provided, a report is generated, and the paperwork is submitted to Blue Cross Blue Shield, Medicare, or any other public or private health plan. This scenario is becoming the standard, regardless of age, diagnosis, or health plan coverage. More and more, the name of the health plan is less important than the quality of the documentation being produced and provided to the reimbursement source.
The process for obtaining reimbursement for services and devices associated with our profession from private health plans is parallel to the process for large public health plans, such as Medicare. To paraphrase an old saying, “As Medicare goes, so go all the others.”
This also holds true for reimbursement advocacy. As clinicians have lobbied over the years for policy changes to provide for services under Medicare—such as the recent victory in postponing implementation of the $1,500 cap on outpatient services—so have professionals and allied organizations campaigned for policy changes to cover needed communication devices.
Today, although reimbursement for services and devices associated with the practice of speech-language pathology continues to require ongoing attention and diligence, it does occur on a routine basis across settings, for many individuals with a variety of communication disorders. Our task at this point is to ensure the caliber of the documentation while increasing the number of individuals receiving these services.
Documentation for Private Health Plans
As a consultant for a large metropolitan insurance company, I have reviewed numerous requests for speech and language services. Observations from this experience suggest that it is of the utmost importance that clinicians provide substantial documentation to the health plan reviewers so as to enable appropriate coverage of all services and devices.
As with any coverage for speech-language pathology services, each patient should check their health plan policy prior to the provision of any services, to confirm coverage. This can be accomplished by reviewing the paper-based policy mailed to the enrollee, by calling the toll-free phone number listed on the back of the insurance card, or by reviewing the health plan’s Web page.
The following are some issues to keep in mind related to reimbursement by private health plans. (Note that, in some areas, reimbursement policies for private health plans differ from Medicare.)
Evaluations. Provide a speech-language evaluation, using formal and informal test results, with recommendations, as appropriate. Be certain to establish reasonable recommendations that are achievable and that fall within the purview of a health insurance program. As an example, it may not be reasonable to expect that a medical health insurance plan would cover recommendations for speech-language pathology to address a reading or math disability.
Plan of treatment. If necessitated by the health plan, develop a plan of treatment that presents measurable goals with achievable timelines. As noted above, be certain that the goals reflect treatment for speech-language disorders covered by the individual’s health plan. Some plans will exclude certain treatments (e.g., myofunctional therapy, fluency, evaluation or treatment of non-speech-generating devices).
Pre-authorization. If the policy requires pre-authorization, a letter of medical necessity (LMN), referral, prescription or any other paperwork, acquire this paperwork prior to implementing the recommendations for treatment.
“Habilitative” and “rehabilitative” services. Determine if a client’s treatment is habilitative or rehabilitative in nature, and check the plan’s coverage of such services. Some policies, based on the coverage selected by the employer or group, cover one but not the other, and other policies cover both.
The paper trail. When speaking to or communicating with health plan staff, record the date, name of person, and summary of discussion. This information may be useful for future communications. Be sure to provide a legible copy by fax, mail, or e-mail of all materials requested by the plan. Don’t forget the requirement for privacy if your practice is a covered entity under the Health Insurance Portability and Accountability Act (HIPAA).
Speech-Generating Devices: Reimbursement Strategies
On Jan. 1, 2000, the process for health plan coverage for speech-generating devices (SGDs) and services changed for all speech-language pathologists. On that critical date, the Centers for Medicare and Medicaid Services (CMS) enacted a Medicare National Coverage Decision for SGDs. Since other plans often follow Medicare’s lead, many state Medicaid programs and private health plans now cover SGDs, communication software, accessories, and mounting systems. (For adults 21 and older, state Medicaid programs are not required to include speech-language pathology services for SGDs as a covered benefit.) While these changes in Medicare are important and have influenced the coverage of SGDs, clinicians should continue to advocate for coverage for services for other expressive communication disorders (e.g., fluency, voice, swallowing, developmental delays) to meet patients’ communication needs.
The publication of seven specific coverage criteria for SGDs under Medicare, effective July 2001, has established a process whereby SLPs work with an individual, their physician, family, and other team members to evaluate, recommend, and provide treatment for and with SGDs. This process is strongly influenced by the SLP, since a certified clinician must sign any evaluation for an SGD and must hold an ASHA Certificate of Clinical Competence. Where licensure is mandated, the clinician must also provide a state license number. It is the impression of this clinician that the same process should be followed by all SLPs, regardless of the health insurance plan, to ensure the highest standard of service provision for all speech-language pathology services and treatment.
Note that a copy of the SLP’s written evaluation and recommendations must be forwarded to the patient’s treating physician. A clinician who follows the Medicare criteria will be using a standard that meets the minimum requirements for most other health plans.
Once the SLP has completed an evaluation, the paperwork process begins. If this service is for more traditional speech-language evaluation or treatment services, the health plan may require a written evaluation or plan of treatment. Once again, the requirements must be confirmed prior to the reimbursement being requested.
However, conducting and writing a complete evaluation with recommendations for devices and services are not the only steps in the process. In the case of an SGD, once a device has been recommended, it must be purchased (e.g. direct purchase or reimbursement to the patient). SGD vendors are generally very cooperative in this phase of the process. In order for a device to be paid, a vendor must “accept assignment “ from Medicare or request prior authorization from the health plan (e.g. Medical Assistance, Blue Cross Blue Shield, and United HealthCare).
If the patient must pay for the device and request reimbursement from the insurance company, the clinician needs to be aware which health plans will reimburse to the patient (e.g. Medicare, private health plans) vs. those that will not (e.g. state Medical Assistance programs). A listing of vendors can be found on the Communication Aids Manufacturing Association’s Web site (http://www.aacproducts.org/).
Specific codes have been assigned to the SGD or equipment, which are different from the codes assigned for services (see the “Bottom Line” column in the May 27 issue by Carolyn Wiles Higdon). The device codes must be included in the speech-language evaluation for the SGD, as well as on the physician’s referral.
As with coverage for all services and devices, in order for reimbursement to occur, specific paperwork must be supplied. This paperwork includes, at a minimum:
  • signed, original speech-language evaluation for an SGD

  • physician prescription or LMN

  • copy of all insurance cards, front and back

When submitting for an SGD, the vendor may require additional information, including a funding information form and an assignment of benefits form, which can be obtained from the specific vendor by calling a toll-free number or downloading from vendor Web sites. For the purposes of an SGD, this paperwork constitutes a “funding packet” that should be submitted to the SGD vendor as soon as possible. The packet should be submitted by mail with a cover letter (see example below).
Dear (Vendor): Enclosed, please find the following:
  • speech-language evaluation for speech-generating device dated _________

  • prescription for (insert device name) (K Code) with (insert name and model of mounting system) (K0546), and (include specific accessories) (K0547)

  • funding information form

  • copy of insurance card, front and back

  • assignment of benefits form

It is anticipated that the materials provided in this packet will be sufficient to allow a decision with subsequent reimbursement for this (purchase/rental). Should additional questions arise, please contact this clinician by phone, fax, or e-mail at the numbers provided.
When submitting for speech-language treatment services, a clinician can submit an invoice, 1500 billing form, or other documentation. When submitting for an SGD, once the vendor receives the funding packet, then the health plan is contacted for prior authorization, if necessary. For those insurers that do not require prior authorization, the process is faster.
In those cases where an individual has primary and secondary insurers, such as Medicare as primary and private insurance as secondary, the delay in response from a secondary insurer can slow the process. Once the vendor receives authorization, the equipment will be shipped to the patient, if mandated by the insurer, or to whomever the patient deems appropriate (e.g. rehabilitation agency, SLP, physician).
This process should not take more than six weeks, but frequently does. A sample retrospective glimpse of 48 funding packets submitted by staff of my practice, Associated Speech & Language Services, Inc., reveals that the average number of days from the date of evaluation to shipping date was 86 days. For Medicare, the number of days decreased to an average of 84.
Resources are available to clinicians challenged with the daily tasks of staying current with policies, procedures, documentation, and other aspects of indirect service provision. The ASHA Web site will soon include a special section devoted to the latest reimbursement information.
In addition, ASHA has convened a task force to pilot and refine an SGD reimbursement protocol, based on the protocol drafted by the Medicare SGD Subcommittee of the Health Care Economics Committee. The purpose of this task is to assist SLPs in submitting for coverage of SGDs and to ensure SLPs’ role as the gatekeepers of Medicare SGD reimbursement decisions. An additional charge to this committee is to make recommendations for a variety of educational opportunities (e.g., telephone conferences, annual convention presentations) focusing on Medicare SGD coverage and documentation.
The task force also will develop a proposal for a mentoring program for SLPs who wish to become proficient in SGD assessment and treatment, and will publicize issues such as documentation for assessments.
While this work is in process, other resources are available now. To obtain a template for guidance in writing a complete evaluation for an SGD, visit the Rehabilitation Engineering Research Center on Communication Enhancement’s Web site (www.aac-rerc.com). This template can be used for individuals of all ages and diagnoses.
In summary, the reimbursement news is good for SGDs. While the provision of services associated with speech-language evaluations and treatment and SGDs can always be more efficient and effective, the field is doing a good job. This has not occurred by coincidence. This success is a direct result of a significant amount of work and collaborations between patients, clinicians, vendors, and advocates (e.g., individuals and national organizations). Without the tireless efforts of these many entities, this success could never have been achieved.
Currently, the goal is to enhance not only the quality of these services, but the quantity as well. The number of individuals requiring AAC services and devices is increasing, as is the number of clinicians becoming more familiar with these strategies and approaches. The availability of training resources including online resources, lectures, mentoring programs, and technical support is continually improving.
This combination of details should lead the field to believe that coverage for services and devices associated with the profession of speech-language pathology will continue to grow.
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July 2003
Volume 8, Issue 13