Saving Medicaid Reimbursement, Texas Style As Texas takes steps to cut its Medicaid budget, the state speech-language-hearing association steps in to mitigate the damage. State of Success
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State of Success  |   May 01, 2018
Saving Medicaid Reimbursement, Texas Style
Author Notes
  • Shannon Butkus, MS, CCC-SLP, is executive director of Butkus & Associates, which provides speech-language treatment in the Greater Houston area. She is also reimbursement chair for the Texas Speech-Language-Hearing Association, a member of ASHA’s Health Care Economics Committee, and an affiliate of ASHA Special Interest Group 11, Administration and Supervision. shannon.butkus@butkusandassociates.com
    Shannon Butkus, MS, CCC-SLP, is executive director of Butkus & Associates, which provides speech-language treatment in the Greater Houston area. She is also reimbursement chair for the Texas Speech-Language-Hearing Association, a member of ASHA’s Health Care Economics Committee, and an affiliate of ASHA Special Interest Group 11, Administration and Supervision. shannon.butkus@butkusandassociates.com×
Article Information
Practice Management / State of Success
State of Success   |   May 01, 2018
Saving Medicaid Reimbursement, Texas Style
The ASHA Leader, May 2018, Vol. 23, 46-48. doi:10.1044/leader.SOS.23052018.46
The ASHA Leader, May 2018, Vol. 23, 46-48. doi:10.1044/leader.SOS.23052018.46
You’re going to cut my Medicaid reimbursement rate?
That’s the question speech-language pathologists have been asking the Texas state legislature since 2011, when lawmakers began debating the state’s Medicaid outpatient therapy expenditures.
The legislature’s concerns were twofold: The state’s Medicaid reimbursement rate for a standard speech-language treatment session was almost double the national median, and Medicaid costs for speech-language services had skyrocketed from $233 million to $426 million in three years.
The question wasn’t if the state would revise its Medicaid program—the question was how.
Legislators repeatedly directed the Texas Health and Human Services Commission to significantly cut payment rates to providers—in some instances, three rate cuts within a year, making it incredibly difficult for clinicians to meet their financial obligations and plan for the future. The commission implemented the cuts swiftly and abruptly, often giving providers less than 30 days’ notice of their intent to change the payment structure.
The Texas Speech-Language-Hearing Association (TSHA) stepped in within a week after the $200 million Medicaid cut was proposed to represent the interests of its members. Through ongoing discussions with legislators and the health commission, TSHA expressed concerns about the severity of the rate cuts and the potential negative impact on consumers and speech-language pathologists.
Multiple payment systems
The effort has had many nuanced layers, mostly because of the unusual Texas Medicaid coding and billing policies for speech-language services, which did not follow guidelines from the American Medical Association or the Centers for Medicare and Medicaid Services.
Instead, Texas Medicaid paid different rates for the same services provided in different settings (home health care, private practice and outpatient facilities). Private practitioners and clinics used timed codes to bill speech-language treatment, but at different hourly rates. Home health billed the same services as untimed codes, at a rate equal to private practice.
Clearly, TSHA needed to balance the interests of these different provider groups and propose what we believed to be fair and reasonable alternatives. Although we consulted with ASHA to develop policy recommendations to submit to the legislature—recommendations we believed to be in the best interests of the profession—we knew in some instances that no solution would satisfy all our members.
Advocacy efforts
In general, we worked with the legislature on three fronts:
Reduce the proposed $200 million cuts to reimbursement rates for speech-language treatment. We worked with the Senate finance chair to reduce the amount targeted for cuts and divide that total into two parts: 67 percent came from rate cuts, and 33 percent was realized through policy changes focused on medical necessity criteria. We also lowered the proposed rate cut by 25 percent to $150 million.
Standardize billing and coding policies. This past legislative session (the Texas legislature meets every other year), we successfully lobbied lawmakers to adopt billing and coding policies for speech-language services that are more consistent with the American Medical Association and the Centers for Medicare and Medicaid Service’s expectations. The Health and Human Services Commission changed the billing structure so that all claims are submitted per encounter rather than in 15-minute increments.
During the implementation phase, we noticed that the commission was trying to deviate from national coding standards by stipulating a minimum number of minutes per encounter. In response, we rallied our members to contact their legislators in opposition and to provide oral and written testimony at a public hearing. Dictating the length of time for a session threatens our designation as autonomous service providers, as it is within our scope of practice to determine the frequency, intensity and duration of services.
Within a month of the hearing, the commission revised its definition of a speech therapy encounter, saying that the length of a session should be consistent with nationally recognized professional standards for a typical session.
Develop recommendations. We developed 15 recommendations to help guide the provision of speech-language services to Medicaid beneficiaries. For instance, we put together a 200-page document outlining best practices; we outlined a new coding structure; we suggested more focus on medical necessity; and we recommended that a therapy services handbook be added to the Texas Medicaid manual to centralize information related to therapy services.

When it was important for members to speak up and out, social media helped us get the word out.

Strategies for success
We attribute our success in dealing with these issues to several strategic decisions and actions.
Build relationships. TSHA has spent years building relationships in the offices of key legislators, including the chairs of the Senate Finance Committee and the Senate Health and Human Services Committee. For the past several years, TSHA representatives have regularly met with the legislators’ staff members to educate them about our profession and the importance of providing services to children with communication delays and swallowing disorders.
As both of these committee chairs are fiscal conservatives determined to reduce Medicaid costs, we knew we could not prevent them from cutting reimbursement rates. But they had indicated their willingness to work with TSHA on Medicaid policy changes when we saw opportunities for improvement.
Be judicious in advocacy activities. TSHA made the deliberate decision to avoid participating in public protests at the state Capitol and to avoid voicing our opposition to the media. We exercised the same caution in determining when and where to provide public comment and testimony. Sometimes these decisions upset our members, who viewed TSHA as failing to be aggressive enough. However, it would have been counterproductive for our members to protest outside of a building where, at the same time, TSHA representatives were meeting cooperatively with key legislators inside.
We also recognized that some measures—for instance, one in the House that would have restored the Medicaid cuts during the special session—had no chance of passing. TSHA knew that showing up at hearings and jamming the phones in response to these measures could compromise our efforts to effect change in areas where we could reasonably make a difference.
This restraint proved invaluable. Legislators have often indicated they appreciated our caution and that it has influenced their decision to maintain an open-door policy with us.
Increase membership engagement. TSHA increased use of social media—the fastest way to engage our members. We shared critical, up-to-date information on Facebook, garnering hundreds of comments and shares that spread our message to a larger audience. When it was important for members to speak up and out, social media helped us get the word out.
Although not everyone agreed with TSHA’s position on every topic, we successfully used social media to boost member engagement in the political process and encourage healthy and respectful debate.
Even with standardized coding and billing, and reductions in overall cuts, the Medicaid situation in Texas remains uncertain. Medicaid has transitioned to managed care organizations and those organizations are implementing value-based payment models. There are 20 of these entities in Texas, some of which are moving to exclusive contracts with specific providers. Stay tuned!
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May 2018
Volume 23, Issue 5