The Quest for Cognitive Treatment Coverage After almost 20 years of effort, Michigan advocates win a cognitive treatment victory. Grassroots 101
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Grassroots 101  |   June 01, 2016
The Quest for Cognitive Treatment Coverage
Author Notes
  • Elaine Ledwon-Robinson, MS, CCC-SLP, is director of speech-language pathology and the pediatric neurorehabilitation program for the University of Michigan Health System. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; 2, Neurophysiology and Neurogenic Speech and Language Disorders; and 13, Swallowing and Swallowing Disorders (Dysphagia). eledwon@umich.edu
    Elaine Ledwon-Robinson, MS, CCC-SLP, is director of speech-language pathology and the pediatric neurorehabilitation program for the University of Michigan Health System. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; 2, Neurophysiology and Neurogenic Speech and Language Disorders; and 13, Swallowing and Swallowing Disorders (Dysphagia). eledwon@umich.edu×
Article Information
Speech, Voice & Prosodic Disorders / Regulatory, Legislative & Advocacy / Attention, Memory & Executive Functions / Traumatic Brain Injury / Grassroots 101
Grassroots 101   |   June 01, 2016
The Quest for Cognitive Treatment Coverage
The ASHA Leader, June 2016, Vol. 21, 20-21. doi:10.1044/leader.GR.21062016.20
The ASHA Leader, June 2016, Vol. 21, 20-21. doi:10.1044/leader.GR.21062016.20
Two 16-year-olds with cognitive impairment were receiving very different treatment in a Michigan pediatric neurorehabilitation program. One teen, who experienced a traumatic brain injury in a car accident, received cognitive therapy targeting attention, memory and executive functioning, paid for under state auto-insurance laws. Speech-language pathologists carefully guided his return to school and, ultimately, community college.
The second teen had significant cognitive impairment from a right-hemisphere stroke following a heart transplant. His speech-language treatment, however, did not target cognitive, memory or attention goals, as his medical insurance did not reimburse cognitive rehabilitation.
After nearly 20 years of advocacy to change this discrepancy, frustrated clinicians and the Michigan Speech-Language-Hearing Association (MSHA) scored a victory. In February 2016, the Michigan Blue Care Network (BCN)—the health maintenance organization of Blue Cross Blue Shield of Michigan—endorsed cognitive therapy as a “safe and effective component of the rehabilitation process” for individuals who have experienced a stroke or traumatic brain injury (unless specific contracts exclude it).
Meetings equal success
Treatment advances in communication and swallowing disorders frequently outpace insurance medical policy guidelines that determine which types of treatments are reimbursable.
In Michigan, a core group of SLPs (comprising MSHA officers and committee members and other SLPs) has met regularly with representatives of Medicaid and commercial insurers (including Blues plans) since the mid-1990s to advocate for policy changes related to various coverage limitations and documentation requirements.
At these meetings, we explained to insurance providers about speech-language treatment and how reimbursement restrictions limit our ability to provide appropriate care to patients who need services.
In turn, the insurers explained to us the process of drafting, refining and changing reimbursement policies.
The reimbursement team carefully crafted goals and priorities for each meeting. Scheduling regular, consistent meetings was essential, as changes in medical insurance policies evolve slowly.
Through this ongoing process, we achieved some successes:
  • Blue Cross Blue Shield (BCBS) extended speech-language coverage to patients with vocal nodules (2002).

  • BCBS agreed to reimburse services for children with developmental speech-language disorders, if the child met specific severity criteria (based on a plan developed at the University of Michigan Health Care System). Prior to this 2006 change, BCBS did not cover treatment for “developmental” conditions.

  • A BCN plan increased the number of covered therapy visits (speech-language treatment and physical and occupational therapy) from 15 to 60 visits for certain major diagnoses, including stroke, head/neck cancer, spinal cord injury and encephalopathy (2009).

  • BCBS allowed independent SLPs to receive direct reimbursement for therapy services (2011).

  • BCBS designated cognitive therapy as a reimbursable service for people who have experienced a traumatic brain injury or stroke; eliminated the physician visit requirement for recertifying speech-language treatment; and lengthened the physician treatment plan certification period from 60 to 90 days (2013).

Treatment advances in communication and swallowing disorders frequently outpace insurance medical policy guidelines that determine which types of treatments are reimbursable.

The cognition challenge
The path to changing medical policy for patients with acquired cognitive impairment was particularly long and difficult, even though Medicare and the state’s no-fault auto-insurance law provide coverage of cognitive rehabilitation.
However, commercial insurers in Michigan (as in most states) have denied reimbursement for cognitive therapy, labeling it “investigational.” The contrast in patient care was significant: If you were cognitively impaired from a car crash, you could receive cognitive therapy, but not if you had a stroke or sports-related concussion, for example.
Every year, in meetings with BCBS, and more recently in dialogue with BCN, our reimbursement team presented information supporting the use of cognitive therapy for acquired neurocognitive disorders. Each year, we requested a change in medical policy to incorporate cognitive therapy as a reimbursable service. We supported this request with research articles, information on the incidence of acquired brain injury, actuarial cost information, and documentation of Medicare and auto-insurance coverage policies.
ASHA provided actuarial information and outcome data from the National Outcomes Measurement System, and ASHA staff participated in a meeting with a commercial insurer. Our preparation, patience and persistence paid off when BCBS reversed its medical policy on cognitive rehabilitation in 2013. This change then supported our continued and ultimately successful negotiations with BCN.
Formula for success
We’ve learned some key strategies in our long fight. If you are navigating the waters of advocacy, we offer some suggestions:
  • Use the resources of ASHA and your state organization to support and inform your team. ASHA’s advocacy website is particularly helpful.

  • Recruit a core team of people who have a thorough understanding of clinical issues and can relate relevant patient stories that connect with insurers.

  • Establish relationships with commercial insurers’ provider relations staff and learn their business constraints.

  • Speak knowledgably and passionately about specific advocacy areas.

  • Be persistent and patient.

Our reimbursement committee took a moment to celebrate the recent BCN cognitive therapy policy change—but our work is not finished. We are reorganizing the priorities of key unresolved advocacy issues, one of which is to expand cognitive therapy to people who have an acquired encephalopathy and/or cognitive difficulties from brain tumor resection.
Margaret Mead’s quote summarizes our efforts: “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” Never doubt that each of us can effect change for our patients, clients and profession.
1 Comment
September 27, 2016
Bethann Ripley
Wonderful work
I was so glad to read this article and gain insight regarding the hard work and advocacy that has been ongoing regarding approval for & reimbursement for cognitive rehabilitation. I have never really understood why 3rd party payors, physicians, other rehabilitation or healthcare practitioners do not see that you cannot really separate language & cognition, nor how they influence all aspects of daily life, whether adults or children, acquired or developmental issues.
Keep up the great work!
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June 2016
Volume 21, Issue 6