One Insurance Payer’s Rule Does Not Apply to All Payer policies—not just ASHA and state requirements—often determine reimbursement decisions. Bottom Line
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Bottom Line  |   November 01, 2018
One Insurance Payer’s Rule Does Not Apply to All
Author Notes
  • Tim Nanof, MSW, is ASHA’s director of health care and education policy. tnanof@asha.org
    Tim Nanof, MSW, is ASHA’s director of health care and education policy. tnanof@asha.org×
Article Information
Practice Management / ASHA News & Member Stories / Bottom Line
Bottom Line   |   November 01, 2018
One Insurance Payer’s Rule Does Not Apply to All
The ASHA Leader, November 2018, Vol. 23, 26-27. doi:10.1044/leader.BML.23112018.26
The ASHA Leader, November 2018, Vol. 23, 26-27. doi:10.1044/leader.BML.23112018.26
“My client’s insurer won’t pay the claim for my treatment, and I don’t understand why.”
Hands-down, claim denial is the most common reason ASHA members contact the association’s insurance reimbursement team for help.
Medicare, Medicaid and private insurers deny claims or refuse to reimburse services for many reasons. Often, the problem is incomplete or inaccurate documentation and/or coding.
Another—and often overlooked—reason for denials is payer-specific policies. These coverage regulations vary from payer to payer and may be related to the type of service provided or condition being treated.
Compliance with payer-specific requirements is an underappreciated aspect of reimbursement. You may be fully licensed and certified as an audiologist or speech-language pathologist, but those conditions alone don’t mean insurers are going to pay for your services and expertise—especially when it comes to services provided by students and clinical fellows (CFs).
Why payers set policies
ASHA, state licensing boards and payers set regulations for different reasons. ASHA standards ensure the appropriate education and training of clinicians and, therefore, the general safety of clients. State licensure laws set minimum standards for qualified professionals to help ensure public safety.
Payer policies, however, specify what services and in what amount are covered, and are designed to ensure the quality of the service delivered.
Three sets of requirements
Reimbursement for services provided by students or unlicensed clinical fellows (CFs) illustrates how all three sets of requirements—ASHA, state and payer—apply.
According to ASHA requirements, a student or unlicensed CF can provide specific services to a client if the student or CF is meeting ASHA standards and the supervisor (who is ultimately responsible) is complying with state supervision law. Supervision requirements vary by state but can exceed ASHA’s educational standards. ASHA and state laws address the safety of the client and the quality of the service.
But following ASHA and state laws does not ensure that the client’s insurer will pay for the service. The payer may have more restrictive and prescriptive policies for student or CF reimbursement. A payer could, for example, have stricter supervision requirements or require the student or CF to have more than a basic or provisional license.
Information, please
Because payer policies vary significantly, two aspects of these policies are critical: the policy details and the availability of that information. Payer policy information is always available to enrolled providers and beneficiaries, but not always available to others, including providers interested in contracting with the plan.
Medicare, Medicaid and other public payers are typically transparent with their policies. However, most private health plans, concerned about marketplace competition, treat their policies as proprietary. A few private insurers, such as United Health Care and certain Blue Cross & Blue Shield plans, make most of their policies and coverage criteria available to the public. But even these companies maintain caveats and plan-specific details that may vary from their public information.
What do the policies cover?
Payer policies dictate what providers can do and how they must do it to get paid.
For example, new graduates looking for a clinical fellowship need to know the state licensure and payer policies that apply to the locations and settings of prospective jobs. Most states, for example, license CFs, but several do not. In those states, most health care settings can’t hire CFs because payer policies overwhelmingly require licensure.
Most health plans pay for services provided by licensed CFs, but some don’t—and some won’t pay for CF services in certain settings (home health, for example). Even CF applicants who meet ASHA and state license requirements should make sure they comply with the policies of payers prominent in the geographic area and care setting they are considering.
Payers often vary in their coverage and reporting of specific diagnoses, evaluations and treatments, and those details can mean the difference between reimbursement and denial. All third-party payers require medical necessity, but some plans have specific exclusions regardless of medical necessity. Knowing plan exclusions related to your area of practice can help avoid denials.
Some plans also have prior authorization requirements and visit limits. By knowing when and how to seek authorization and tracking visits, you can avoid denials for services you have already provided.
Even if you follow all the rules, your claim may still be denied. All payers allow providers to file appeals—but again, each payer has its own exceptions process, appeals procedures and documentation requirements. Knowing these can help circumvent denials and what might initially appear to be hard limits.
ASHA can help
ASHA has resources for members related to all of these licensure and payer-specific policy issues:
New Guidance Turns Former Therapy ‘Caps’ Into ‘Thresholds’

Speech-language pathologists who provide outpatient services to Medicare patients must flag reimbursement claims if a patient’s combined speech-language treatment and physical therapy (PT) exceed $2,010 in 2018, according to recently issued guidance. In addition, claims totaling more than $3,000 for any one Medicare patient could undergo medical review.

The guidance, from the Centers for Medicare and Medicaid Services, clarifies billing issues in the wake of the February 2018 repeal of Medicare outpatient therapy caps and the therapy caps exceptions process.

Under the new law:

  • The former cap amounts ($2,010 for occupational therapy and $2,010 for combined speech and PT) are now “threshold” amounts. Claims beyond the threshold must include the –KX modifier, which confirms the patient’s medical record includes documentation that the services are medically necessary.

  • Claims that surpass $3,000 for occupational therapy or speech and PT combined for one patient are subject to targeted medical review.

The guidance also explains that clinicians should use an Advance Beneficiary Notice of Noncoverage (ABN) to notify patients when Medicare will not pay for their services, either because the service is not medically necessary or because Medicare does not cover the service.

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November 2018
Volume 23, Issue 11