The Clinical Fellow Licensure Conundrum Licensure, billing and reimbursement for clinical fellows can differ among states and insurers. Here’s what you need to know. On the Pulse
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On the Pulse  |   November 01, 2016
The Clinical Fellow Licensure Conundrum
Author Notes
  • Susan Adams, Esq., is director of ASHA state and regulatory advocacy. sadams@asha.org
    Susan Adams, Esq., is director of ASHA state and regulatory advocacy. sadams@asha.org×
  • Heather Bupp, Esq., is ASHA director of ethics. hbupp@asha.org
    Heather Bupp, Esq., is ASHA director of ethics. hbupp@asha.org×
  • Kate Ogden, MPH, is an ASHA health policy associate. kogden@asha.org
    Kate Ogden, MPH, is an ASHA health policy associate. kogden@asha.org×
Article Information
Practice Management / Professional Issues & Training / On the Pulse
On the Pulse   |   November 01, 2016
The Clinical Fellow Licensure Conundrum
The ASHA Leader, November 2016, Vol. 21, 34-35. doi:10.1044/leader.OTP.21112016.34
The ASHA Leader, November 2016, Vol. 21, 34-35. doi:10.1044/leader.OTP.21112016.34
Will private and government health plans cover services provided by clinical fellows? Do they need a special license? Clinical fellows and their supervisors need to be familiar with the licensure and billing laws in their state to make sure they are in compliance with the legal and ethical considerations surrounding CF-provided services.
State licensing boards and insurance providers have specific requirements about qualifications, licensure, billing and reimbursement for clinical fellows—and the rules are constantly changing. Here’s a look at some of the relevant issues.
State licensure
State licensing requirements for clinical fellows vary from state to state. Most states issue a provisional, limited or temporary license to clinical fellows; a few states have no form of licensure for clinical fellows.
However, state licensure and practice policies do not always align with reimbursement policy. For example, five jurisdictions (Connecticut, District of Columbia, Massachusetts, Pennsylvania, New York) require licensure applicants to have completed a clinical fellowship, but don’t license clinical fellows. In these states, clinical fellows are considered students for the purposes of reimbursement and, as such, may be subject to 100-percent direct supervision.
Alabama and Tennessee register clinical fellows but do not license them. This distinction is important, as CFs in these states are also considered students for purposes of reimbursement.
Discover information on each state’s interim licensure policies online (click on your state, then on the licensing link, scroll to “interim practice” regulations).

Most states issue a provisional, limited or temporary license to clinical fellows; a few states have no form of licensure for clinical fellows.

Medicare
Medicare, of all payers, offers the clearest and most consistent billing guidance for clinical fellows. Medicare requires audiologists and speech-language pathologists to have state licensure to enroll as a provider, and its policy manual defines a qualified provider as a clinician who is “licensed or certified by the state to furnish therapy services.” Clinical fellows with state provisional or temporary licenses may enroll in and bill Medicare for their services.
However, clinical fellows in states that do not issue provisional or temporary licensure are not considered qualified providers and cannot enroll in or bill Medicare. Without licensure and qualified provider status, the clinical fellow is considered a student, subject to student supervision requirements.
Under Medicare Part B (outpatient) regulations, students (including unlicensed CFs) must be directly supervised at all times by a supervising speech-language pathologist, who assumes all responsibility for the services provided. The supervising SLP may not engage in another task or supervise another clinical fellow at the same time.

Clinical fellows in states that do not issue provisional or temporary licensure are not considered qualified providers and cannot enroll in or bill Medicare.

Medicaid
Qualified-provider requirements for Medicaid differ by state and by practice setting. Each state’s Medicaid program determines its own requirements for qualified providers, though many states follow Medicare guidance and require licensure.
Clinical fellows need to confirm the requirements for billing, including who is considered a qualified provider, with the state Medicaid program specific to the setting where services will be provided. Visit ASHA’s Medicaid Toolkit for general information on Medicaid regulations for qualified providers and supervision.
Private health plans
Private health plans determine their own requirements for qualified providers. Many follow Medicare guidance, but others set their own stricter or more lenient rules. Providers should contact payers for clarification. ASHA’s Issues in Ethics statement, Representation of Services for Insurance Reimbursement, Funding, or Private Payment (2010), offers additional guidance.
Ethical considerations
Clinical fellows in all states may practice in accordance with Rule II-B of ASHA’s Code of Ethics, which clarifies that clinical fellows may provide clinical services, as long as doing so is consistent with applicable local and state laws and regulations. Clinical fellows come under the jurisdiction of ASHA’s Board of Ethics as soon as they apply for certification, with or without membership.
The ASHA Board of Ethics does not consider practice by clinical fellows to be unethical assuming they comply with ASHA certification requirements, the Code of Ethics, and any applicable local and state laws and regulations.
ASHA topics related to clinical fellows and CF supervision are addressed in several Issues in Ethics statements:
  • Clinical Services Provided by Audiology and Speech-Language Pathology Students (2013)

  • Responsibilities of Individuals Who Mentor Clinical Fellows in Speech-Language Pathology (2013)

  • Supervision of Student Clinicians (2010)

Violating local, state or federal laws and regulations related to providing clinical services, professional qualification or reimbursement also is likely to violate the ASHA Code of Ethics, a state code of conduct, or both. Principle IV, Rule R requires that “Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice, research ethics, and the responsible conduct of research.”
The bottom line: State licensing boards and payers—including Medicare, Medicaid and private health plans—ultimately decide who is considered a qualified provider. ASHA, on the other hand, reports and provides interpretations of how policies and rules apply to clinical fellows and their supervisors. Clinical fellows and their supervisors should always confirm qualifications, licensure, billing and reimbursement guidelines and restrictions with their state and payers before providing services.
For questions about state licensure, contact sadams@asha.org; for ethics questions, contact ethics@asha.org; for billing and reimbursement questions, contact kogden@asha.org.
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November 2016
Volume 21, Issue 11