Federal Bills Would Recognize SLPs as Medicare Providers Take Action Now on S. 568 and H.R. 1995 Policy Analysis
Policy Analysis  |   October 01, 2004
Federal Bills Would Recognize SLPs as Medicare Providers
Author Notes
  • Nancy B. Swigert, a former ASHA president, is a member of ASHA’s Health Care Economics Committee. A speech-language pathologist, she is president of Swigert & Associates, Inc., in Lexington, KY. She can be reached at nswigert@aol.com.
    Nancy B. Swigert, a former ASHA president, is a member of ASHA’s Health Care Economics Committee. A speech-language pathologist, she is president of Swigert & Associates, Inc., in Lexington, KY. She can be reached at nswigert@aol.com.×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   October 01, 2004
Federal Bills Would Recognize SLPs as Medicare Providers
The ASHA Leader, October 2004, Vol. 9, 1-16. doi:10.1044/leader.PA.09182004.1
The ASHA Leader, October 2004, Vol. 9, 1-16. doi:10.1044/leader.PA.09182004.1
Imagine that your favorite uncle, who is covered by Medicare, has had a stroke and needs outpatient physical, occupational, and speech-language therapy. What options are available as you help him seek services? All three therapy services could be provided in the outpatient department of a hospital or at a rehabilitation agency. But only physical or occupational therapy would be available at the private office of an independently practicing clinician because in the Medicare statute, occupational therapists and physical therapists are recognized as private practitioners who can bill Medicare directly for their services. Speech-language pathologists are not. Bills currently pending in the U.S. Senate and U.S. House of Representatives would remedy that inequity. S. 568, sponsored by Sen. John Ensign (R-NV), and H.R. 1995, sponsored by Rep. Fred Upton (R-MI), need your-and your legislators’-support. There are only a handful of co-sponsors who have signed on to endorse this important legislation.
Passage of the bills would allow Medicare beneficiaries more choices when seeking speech-language treatment services. Suppose your uncle does not live near a hospital that has outpatient services, but is near an SLP who is in private practice. If that clinician were recognized as a private practice provider, the clinician could see your uncle and bill Medicare directly. Your uncle would be responsible only for his co-pay. Without a correction to the Medicare statute, your uncle may have to be transported a long distance to find a hospital outpatient provider.
This legislation also would give SLPs in private practice the choice to provide services to patients covered by Medicare and to bill Medicare directly for those services. This would increase the patient population that a clinician in private practice could see. This choice might be appealing to SLPs in private practice not only because it could increase their caseload, but because Medicare regulations about covered services and reimbursement are easier to understand than the plans of many private insurers. Medicare, for example, publishes an outpatient fee schedule and provides information in Local Coverage Determinations about covered services.
S. 568 and H.R. 1995 seek to accomplish private practice status for SLPs through a technical correction in the definition of outpatient speech-language pathology services. A new paragraph would be inserted into the statute to define the term “outpatient speech-language pathology services” as having the meaning given the term “outpatient physical therapy services.” Currently the statute uses the language “outpatient physical therapy services (which includes outpatient speech-language pathology services).” Having only this parenthetical inclusion of speech-language pathology in the legislative language has caused significant problems in the past, including the shared $1,500 cap on Medicare outpatient services.
Impact on Reimbursement
So you’re not in private practice and don’t plan to be. Will this legislation have any effect on you? It might have a significant impact on the amount of reimbursement received for each CPT code. When a procedure is accepted (or periodically reviewed) by the American Medical Association, the AMA uses a formula to determine a value for each procedure regarding the work and practice expense associated with providing the service. Because some services are more expensive to provide or carry greater risk than others, a resource-based relative value scale (RBRVS) was established to rank the value of all codes for reimbursement. Currently, SLPs’ “work” is not recognized as part of the formula. SLPs are given credit only for the practice expense-our time only. We do not receive credit for our judgment, skill, stress, and physical and mental effort. Conversely, physical therapists and occupational therapists are allowed to measure the amount of “work” they do and this information is calculated in the Resource Based Relative Value System (RBRVS) formula.
A representative of the Center for Medicare and Medicaid Services (CMS) sits on this AMA committee, engages in the discussions, and participates in the AMA decisions determining the value of each procedure. ASHA provides data on all the procedures affecting speech-language pathology and audiology. After the AMA renders its decision on the value of work and practice expense, CMS then revalues each code according to their standards. Congress established these standards to pay for health care services to Medicare recipients-in essence, designating a fixed pot of money from which all services must be paid. In recent years, these relative values have been adopted as the framework of reimbursement for many private insurers and HMOs.
CMS representatives have indicated that passage of this bill would not guarantee that SLP’s “work” would be recognized in the formula, but without this legislative change we have very little chance at achieving this recognition. Until ASHA is fairly certain that the work of SLPs will be valued in the formula, the Association is refraining from pursuing major revisions to CPT codes over concern that any new codes might be valued at a lesser rate than current reimbursement levels.
So whether or not you ever intend to hang out a shingle and bill Medicare for services, these bills are important to you. They will give SLPs the same status in Medicare statute as our rehabilitation colleagues-something that is long overdue! Take a few minutes to urge your senators and representative to cosponsor S. 568 and H.R. 1995.
Visit ASHA’s “Take Action” advocacy site at http://takeaction.asha.org where you’ll find model letters you can personalize (including information about yourself, your practice, your patients, etc.) and e-mail directly to your legislators. We can’t be successful in obtaining the ability for SLPs in private practice to bill Medicare directly without your help. Please take time to advocate for yourself or on behalf of your colleagues.
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October 2004
Volume 9, Issue 18