Advocacy Brings Success in Reimbursement Appeals In reimbursement appeals, advocacy backed with relevant data can be a powerful tool. Four recent cases—involving treatment for Parkinson’s disease, articulation problems, autism, and vocal cord nodules—illustrate how clinicians and consumers, using ASHA’s expertise, can overturn claims denials. Speech-Generating Devices In Arkansas, speech-language pathologist Catherine Jarrett had nearly given up ... Grassroots 101
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Grassroots 101  |   April 01, 2002
Advocacy Brings Success in Reimbursement Appeals
Author Notes
  • Janet McCarthy, is ASHA’s private health plans adviser. Contact her at jmccarty@asha.org.
    Janet McCarthy, is ASHA’s private health plans adviser. Contact her at jmccarty@asha.org.×
Article Information
Speech, Voice & Prosodic Disorders / Practice Management / Regulatory, Legislative & Advocacy / Grassroots 101
Grassroots 101   |   April 01, 2002
Advocacy Brings Success in Reimbursement Appeals
The ASHA Leader, April 2002, Vol. 7, 1-20. doi:10.1044/leader.GR.07062002.1
The ASHA Leader, April 2002, Vol. 7, 1-20. doi:10.1044/leader.GR.07062002.1
In reimbursement appeals, advocacy backed with relevant data can be a powerful tool. Four recent cases—involving treatment for Parkinson’s disease, articulation problems, autism, and vocal cord nodules—illustrate how clinicians and consumers, using ASHA’s expertise, can overturn claims denials.
Speech-Generating Devices
In Arkansas, speech-language pathologist Catherine Jarrett had nearly given up her attempt to get coverage for a speech-generating device for a patient with a rare form of Parkinson’s disease.
“The patient had a complicated diagnosis,” she said. “His illness caused motor problems, and he had to have a tracheostomy. He had no oral communication. Although there were no cognitive deficits, he could only communicate by giving a thumbs up or thumbs down.”
To enable the patient to handle his property and family affairs, “an AAC device was his only option.” After researching the options, Jarrett chose the Prentke Romich Pathfinder as the device that best met the patient’s needs, and received assistance from a company representative.
Jarrett’s search for reimbursement proved much more difficult. She submitted the paperwork to Medicare with a letter from the family and a physician letter of medical necessity. The claim was denied because Medicare does not reimburse for speech-generating devices for residents of skilled nursing facilities. Next Jarrett sent the package to the supplemental insurer, Mutual of Omaha. The company’s denial stated that the insurer considered the device “a patient convenience item.”
“Those were fighting words for me,” she said, “knowing how much this man needed to communicate in order to handle his affairs.”
She called the patient’s family and ASHA, where she received assistance, including a claim review outline to use in reporting the patient’s cognitive status, reasons for device selection, and prognosis.
As a result, after five months Mutual of Omaha agreed to pay for 80% of the device.
Success in appeals, Jarrett says, requires “good documentation, perseverance, and supporting data.”
Articulation
Katherine Hurst is a busy 4-year-old with lots to say. But she has difficulty with speech and cannot clearly articulate all of her words. Her family’s large health plan refused to cover needed speech-language pathology treatment.
ASHA challenged the insurer’s argument that speech-language pathology services were “educational and not restorative.” ASHA responded that the services were restorative because middle-ear disease caused the loss of speech function. Recurrent otitis media with conductive hearing loss was the basis of Katherine’s speech disorder.
Regarding the issue of “medical necessity,” ASHA argued that speech-language services were “essential and necessary” in treating the child’s illness-related speech problem.
“The requirement that one must first possess an ability and then lose it does not allow for the medically related therapy needs of infants and young children,” ASHA’s letter stated.
To bolster the Hurst’s case, ASHA cited a statement by the American Academy of Pediatrics noting the correlation between middle-ear disease and hearing loss, and the effect of this condition on speech and language development. Six months of advocacy paid off when the health plan reversed its denial.
Autism
A California mother recently used her legal skills to press one of the nation’s largest federal health care plans to gain reimbursement for speech-language services for her autistic son. In her appeal, Jill Escher charged that the policy of the Blue Cross Blue Shield Federal Employee Program (BCBS FEP) discriminates against children with autism, and is in error on matters of contract law. She pressed for a policy change for all such cases, not just a reversal of her individual appeal.
To support Escher’s case, ASHA noted in a letter to BCBS FEP that autism is a neurobiological disorder with associated speech and language impairments. Speech-language treatment provides the same benefits to individuals with autism as medication or medical procedures provide to people with similar physical or neurobiological disorders, which are typically covered by health plans.
ASHA’s letter stated, “Autism is treatable, with speech-language pathology services used to improve communication. Over 200 studies support the effectiveness of language intervention for children, including those with language disorders associated with autism.”
Escher didn’t stop with the insurer. “I fought BCBS FEP tooth and nail for seven months,” she said. Next, she contacted the federal Office of Personnel Management (OPM), which contracts with the insurer, and asked for a written decision indicating that the insurer was in error in its blanket policy that speech-language services are not medically necessary for children with autism. “I also believe it is discriminatory policy under the Rehabilitation Act.” Her next step, she said, would have been to file a lawsuit in federal court. Unexpectedly, however, after that long battle, the company reversed the denial and paid her claims.
“When insurance companies are threatened with a precedent, they will pay out rather than change their policy,” Escher said. “That’s why families have to fight so hard in every case. Companies strongly resist changing their policies.”
Vocal Cord Victory
It took 30 years, but the Michigan Speech-Language-Hearing Association and speech-language pathologists won a landmark reimbursement victory for patients with vocal cord nodules.
These nodules, a common cause of voice dysfunction from overuse or improper use of the voice, can be successfully treated with voice therapy, thus avoiding surgery.
For decades, Blue Cross Blue Shield of Michigan (BCBSM) refused to reimburse for speech services prior to surgery. As far back as 1971, Michael Rolnick, director of speech-language pathology at William Beaumont Hospital in Royal Oak, MI, first argued to BCBSM that voice therapy could reduce the need for vocal cord surgery. Even the noted otolaryngologist and voice specialist Friedrich Brodnitz wrote a letter of support.
BCBSM refused to change its policy, but the clinicians and state association kept up the pressure. They won the support of the state’s otolaryngologists, patients and their families, employers, and used data from William Beaumont Hospital, as well as ASHA’s resources.
“It also helped that our referrals came from otolaryngologists. That showed that even the surgeons believed that a speech-language pathologist with specialized training should provide this treatment.”
Now it is standard medical practice to use voice treatment to dissolve vocal cord nodules without surgery. As a result, BCBSM no longer classifies speech services as a noncovered presurgical service.
Reimbursement is retroactive to June 22, 2001.“We’re thrilled, and we have notified all the otolaryngolotists in Michigan, “ Rolnick said.
“After 30 years of effort, our patients finally can be assured they will receive appropriate care.”
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April 2002
Volume 7, Issue 6