The Top 10 Medicaid Challenges in Schools From paperwork to coding to appealing denials, Medicaid reimbursement can be time-consuming and complicated. Here are some suggested fixes. Bottom Line
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Bottom Line  |   September 01, 2017
The Top 10 Medicaid Challenges in Schools
Author Notes
  • Laurie Alban Havens, MA, CCC-SLP, is director of ASHA private health plans and Medicaid advocacy. lalbanhavens@asha.org
    Laurie Alban Havens, MA, CCC-SLP, is director of ASHA private health plans and Medicaid advocacy. lalbanhavens@asha.org×
Article Information
School-Based Settings / Practice Management / Bottom Line
Bottom Line   |   September 01, 2017
The Top 10 Medicaid Challenges in Schools
The ASHA Leader, September 2017, Vol. 22, 30-32. doi:10.1044/leader.BML.22092017.30
The ASHA Leader, September 2017, Vol. 22, 30-32. doi:10.1044/leader.BML.22092017.30
Medicaid helps pay for school-based health care services—including hearing and speech treatment—for more than three-quarters of students who receive them. And Medicaid, like all insurers, has many requirements that schools—and providers—must meet to receive the funds.
Medicaid rules and regulations are set by each state and district, but most school-based audiologists and speech-language pathologists are likely to encounter some form of the following 10 challenges.
1. Paperwork
School districts, of course, require administrative records, but they often require additional paperwork for Medicaid students. In some cases, therefore, providers must enter information twice to meet the unique payer and administrative requirements. Some districts use software or data systems that serve both purposes, but many do not.
Also, many districts require providers to complete Medicaid paperwork for all students on their caseload, even though not all are Medicaid-eligible. The districts rationalize that because students become eligible at different times during the year, it’s easier to have the data at hand rather than re-create it later. Also, completing paperwork for all children minimizes the possibility of differential treatment of those on Medicaid.
What’s the fix? Ideally, more districts will use software that captures IEP and Medicaid information at the same time. Consider asking for this change.

Completing paperwork for all children minimizes the possibility of differential treatment of those on Medicaid.

2. Prior authorization
All payers, including Medicaid, review claims for eligibility. Additional scrutiny is especially common with Medicaid managed care plans. Providers must get approval before beginning treatment, and often the approval is for a limited period of time or number of sessions, requiring providers to obtain re-authorization to continue treatment beyond the limit.
What’s the fix? Ask if other personnel are available to place calls to get authorization. If not, request that you be allocated time for this task.
3. Specific rules
Each state defines how it administers its Medicaid program, and each plan determines the policy for implementation. These policies form the framework for local education agencies (LEAs), which then establish requirements for providers. The multiple levels of information-sharing may result in misinterpretation or misunderstanding of the rules. For instance, the state may say that SLPs are qualified “licensed health care professionals,” but the district may recognize only physicians.
Some LEAs add extra rules to comply with other district-specific requirements. The challenge is to make sure that all LEA directives meet the requirements of the state plan.
What’s the fix? Review the state plan. If you have trouble getting a copy of the plan, work through your state speech-language-hearing association. Ask your LEA for its specific plan as well.
4. Denials
Prior authorization does not guarantee coverage, and Medicaid may deny reimbursement for authorized services. Don’t assume that if the agency denies the service, the service is unnecessary. A denial usually means that the information submitted was not adequate to make the determination. When Medicaid denies treatment for medically necessary services, providers need to appeal, providing documentation to support the claim. Denials are often overturned.
Some school systems want to appeal, because the denial means a loss of revenue for the school district. Other LEAs may decide an appeal is not worth the effort. As a fundamental principle, however, SLPs may want to appeal to demonstrate that their services are needed and meet medical necessity and other criteria.
What’s the fix? ASHA has resources—including definitions of medical necessity and an explanation of why speech-language services meet the definition of medical necessity—to help providers prepare appeals.
5. Qualified providers
Holding state licensure and/or ASHA’s certificate of clinical competence does not guarantee that an audiologist or SLP can bill for Medicaid clients. Providers must often apply to the Medicaid agency; in some states, however, the LEA has a provider number and individual SLPs can bill under that number. Requirements also vary for speech-language pathology assistants and clinical fellows.
What’s the fix? Providers should check the definition of who is a qualified provider in their specific setting, usually through the state Medicaid agency.

Holding state licensure and/or ASHA’s certificate of clinical competency does not guarantee that an audiologist or speech-language pathologist can bill for Medicaid clients.

6. Coding
Providers use two sets of codes. The first—Current Procedural Terminology (CPT®, American Medical Association) codes—used by Medicare and insurance companies, indicate procedures. Most Medicaid agencies use the codes, though some have developed their own coding requirements. If the LEA requires the codes, the provider—or other personnel—must include that number in the record and/or billing sheet.
The second is the International Classification of Diseases-Clinical Modification (ICD-10-CM), which indicates diagnoses. The physician or team may assign the code, though audiologists and SLPs can diagnose certain codes within their scope of practice.
What’s the fix? There is no “fix” for this challenge—just a clarification on the types of codes that are needed. ASHA’s practice management website has information about CPT and ICD-10 codes that audiologists and SLPs use.
7. The future
The future of Medicaid is uncertain. National health plan proposals under consideration include cuts in Medicaid, and how those cuts could affect service delivery models is unknown.
What’s the fix? Keep informed about changes (see “Our Voices Are Powerful”). Sign up for ASHA Headlines. Find out how the decisions will affect the services provided in your state. Look for opportunities to provide input and recommendations by serving on committees that include providers in the stakeholder group. At the same time, continue to document treatment outcomes that demonstrate the value of the services you provide.
8. Managed care organizations (MCOs)
More states are moving to the managed care model, in which the state Medicaid agency contracts with a plan to provide all the health care services that an enrollee needs. The plan then makes its own rules for what services are approved, and often caps the number of allowed sessions.
What’s the fix? The more information you get about how plans work, the better equipped you are to design treatment programs that align with the MCO criteria.
9. Burden
Some LEAs choose not to apply for Medicaid reimbursement because of the multiple tasks that are required: obtaining parent consent, dealing with administrator directives, and adjusting to electronic health record and data entry. However, because of their need for funding, more districts are deciding to bite the bullet and apply for reimbursement for Medicaid-eligible students.
What’s the fix? Just make sure you are aware of—and comply with—the specific requirements.
10. Documentation
Documentation of services and sessions is a challenge for all providers, regardless of setting.
What’s the fix? Use the available resources, starting with ASHA’s Practice Portal, to make sure your documentation reflects medical necessity and other requirements. Where possible, work with other audiologists and SLPs in the district to develop streamlined documentation (if allowed) that still meets the requirements and that accurately records the medically necessary treatment provided.
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September 2017
Volume 22, Issue 9