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Medicaid Dilemma

Vol. 15 •Issue 45 • Page 6
Medicaid Dilemma

Billing obstacles in the schools

With their many responsibilities and the tight time frame they're given, school speech-language pathologists continue to struggle with the challenges of Medicaid billing.

Medicaid is a long-standing, low-income insurance program that pays for certain health care services for eligible individuals. Many school districts bill Medicaid for special education services to obtain additional revenue.

This is a relatively new phenomenon for school speech-language pathologists and audiologists that gained more attention with the implementation of the Individuals with Disabilities Education Act (IDEA) of 1997.

One complication speech-language pathologists face is miscommunication and misunderstandings, especially where a school district is just beginning to implement the program.

"You've got Medicaid offices in states that have never worked with schools before. They're learning about how it fits into the school culture, and sometimes they don't understand the questions they're getting because they're used to a medical culture," Lissa Power-deFur, PhD, CCC-SLP, chair of the Department of Education, Special Education, Social Work and Communication Disorders at Longwood University in Farmville, VA, told ADVANCE. Likewise, school districts need to understand the health culture of Medicaid.

At the federal level, Medicaid uses the American Speech-Language Hearing Association's (ASHA) Certificate of Clinical Competence as the qualification standard for speech-language pathologists. However, since Medicaid is a federal-state program, each state may establish its equivalency to the federal standard, which must be approved by the federal Medicaid office.

Similarly, state Medicaid plans can vary as long as they're approved by the federal Medicaid office, Centers for Medicare and Medicaid Services (CMS). However, because the states are often left to take care of any discrepancies, some challenges maythe qualifications of supervisory health service professionals cannot be changed.

"The dilemma is that states can certify individuals to provide speech and language services in the schools under certification requirements that may not be the same as the requirements for state license or for ASHA certification," said Kathy Whitmire, PhD, CCC-SLP, director of School Services in Speech-Language Pathology for ASHA, in Rockville, MD. "These individuals would not be qualified tocannot provide services that are reimbursed by Medicaid unless their services are under the direction of a federally qualified speech-language pathologist ."

ASHA regularly receives calls from speech-language pathologists regarding billing practices that seem inconsistent with Medicaid requirements and/or ASHA's Code of Ethics. For example, one individual complained that her supervisor gave her a stack of blank billing forms and told her to "just sign the forms." Another clinician told of a supervisor who asked her for her license number so it could serve as authorization on every billing form.

"Our Code of Ethics is very clear in that we need to keep paramount the best interest of the client. We can't delegate responsibilities to individuals who are not trained and prepared to carry out those responsibilities. Good judgment and Medicaid regulations tell us that's not how you direct and supervise services," said Dr. Whitmire.

Another primary concern is that many speech-language pathologists who are qualified under Medicaid often are asked to provide a high level of direction or supervision authorize Medicaid payment for services rendered by non-qualified individuals without being given adequate time to look over documentation and make visits to a client's treatment sessions.

"This can be a very substantial amount of time if they're going to carry out these responsibilities in a manner that is within legal and ethical boundaries," said Dr. Whitmire.

"The complaint is that they're signing the billing form, which makes them legally responsible for the care rendered, but they don't have a good, solid feel that the services are being rendered on a professional level," said Mark Kander, MA, director of Health Care Regulatory Analysis at ASHA. "It must be made clear to supervising speech-language pathologists that they assume professional and legal responsibility for the services provided."

Often, school districts will dismiss the paperwork as a mere formality.

"We [ASHA] have to tell them that there is some liability there even though school districts will often tell the speech-language pathologist, 'Don't worry. You're just signing this form so we can submit it to Medicaid. It's a formality–you aren't responsible.'

"Well, they are," said Kander. "Let's make it very clear that it's not just a minor thing they're signing." There are many approaches to overcoming this problem, he said, but the bottom line is that qualified clinicians need time to examine documentation and be involved in a child's initial evaluation and subsequent treatment.. This is the essence of meeting the Medicaid requirement that services are rendered ""under the direction of" a qualified speech-language pathologist, said Kander.

The time that's involved will vary depending on the caseload and the expertise of the clinicians who are providing the services.

"It should include face-to-face observations of the student receiving services, meetings on a regular basis with the clinician providing the services, and a review of intervention plans, progress notes, session notes and any other relevant documentation," said Dr. Whitmire. "This is going to require time."

According to Kander, the "under the direction of" regulatory requirement is interpreted unreasonably by many school districts and/or states. For example, one state department of education only required the supervising clinician to be available by telephone.

Last year's update to the preamble to the Medicaid regulations for audiologists has provided a good template for defining adequate supervision in speech-language pathology.

"CMS knows these same standards for supervision are appropriate for speech-language pathologists, but for whatever reason only audiology was addressed when the regulation was revised," said Kander.

The preamble advises that the supervising clinician see the child at the beginning of treatment and periodically thereafter, be familiar with the treatment plan and review the need for continued services throughout treatment.

Another crucial element is the stipulation that the clinician "must spend as much time as necessary directly supervising services to ensure children are receiving services in a safe and efficient manner that ensures quality care." 1

"That at least makes it a little more clear, although it's still somewhat nebulous," said Kander. The supervising individual also must assume professional responsibility for the services provided.

There are other ways the latest revisions to the requirements for audiologists can benefit speech-language pathologists. In addition to seeing a child at the beginning of and periodically during treatment, the revisions call for the audiologist to be familiar with the treatment plan and have continued involvement in the care provided and review the need for continued services throughout treatment.

School speech-language pathologists should never assume their school district administrators understand Medicaid requirements. Administrators are trained and experienced in education law, not Medicaid regulations, said Dr. Whitmire.

The Medicaid regulations are extensive and many school-based clinicians have not had prior experience with federal and state Medicaid requirements.

"Some school districts have begun billing Medicaid without recognizing how much time it takes to understand it and do it right," said Dr. Power-deFur, chair of the Working Group on Medicaid Supervision for ASHA.

Many districts are likely letting unqualified people [provide services] that are billable to Medicaid because they don't understand the Medicaid requirements well enough. It is important for speech-language pathologists and district administrators to request training in Medicaid requirements to ensure a full understanding of the policies and procedures.

Clinicians should use this as an opportunity to talk to administrators about the standards and potential liability they face if they don't follow the standards correctly. If school districts obtain funds inappropriately, they are liable for returning them, said Dr. Power-deFur.

Medicaid can audit school records at any time. In addition to reviewing record keeping, auditors scrutinize the goals and objectives, services provided, and data collected on student progress and attendance.

"This is really about accountability for the money you're getting. Accountability is associated with following the rules concerning that money. If you don't follow the rules, you don't get the money," said Dr. Power-deFur.

Medicaid has no provision for what is actually done with the funds, so clinicians should work closely with the school district to make sure a percentage of the money is returned to the special needs programs that generate the funds. Clinicians also should negotiate with the school districts to pay for their licensure and certification fees, continuing education, or laptop computers to help them keep up with paperwork.

"Speech-language pathologists have been successful in efforts to funnel the funds because the staff can say they're the ones bringing all this money into the school district," said Kander.

When a school district hires an outside billing agency to process the claims, he recommends that the company not be paid based strictly on a percentage of billed revenue.

"They're apt to bend the rules to increase the dollars billed because then they'll make more money," he said.

Individuals who have questions about billing should consult their state Medicaid plan.

"It's always a good idea to go to the state Web site and find the plan. Some can be very complex and difficult to work through. Professionals also can contact their state Medicaid office and speak to a staff member to help clarify any confusion they have or provide needed information," Dr. Whitmire said.

ASHA provides technical assistance and professional consultation regarding Medicaid.

Districts should have an understanding within their policy and practice of the steps that can be taken if a supervising clinician is uncomfortable with the program that the supervisee is delivering or finds it inadequate or inappropriate.

However, such a situation could be used positively for professional training and for identifying an area for professional growth, according to Dr. Whitmire. "But it would be very helpful if that's addressed up front so people aren't left wondering what to do when that situation arises."

"If a qualified speech-language pathologist is supervising somebody who can bill Medicaid 'under the direction of' but doesn't meet ASHA or state education credentials to provide services independently, what does the clinician do when he or she sees something being done inappropriately?" asked Dr. Power-deFur.

Ethical issues and how to deal with them need to be discussed in the beginning stages of implementing Medicaid billing practices. Clinicians must make sure that what they're doing is permitted under state and federal guidelines and that their supervisor is not asking them to do something that's unethical.

"We have the potential of losing our certification and our license if we are found in violation of our ethics. If that is the case, the district would no longer be able to bill Medicaid for services provided by that speech-language pathologist," said Power-deFur.

The adverse implication also goes to the district because it loses its revenue source, she added. "It's not that special education directors aren't ethical; they just don't know about the ethical situations they may be inadvertently creating. Sometimes you have to paint a picture for them."

She cautioned speech-language pathologists that they should make sure the roles, responsibilities and expectations of both the administration and the clinician are clear before providing services.

"Before signing off, you need to work out the parameters," she advised. Do you get staff development on how to supervise? How much time are you going to have in order to be able to do this additional duty? Are you given the time to observe therapy to make sure that what you're signing off on actually happened?

"Too many of us assume people know what we need, so we need to speak up," she said. n


1. Centers for Medicare and Medicaid Services. (2004.) Medicaid Program; Qualifications for Audiologists. Federal Register, 69 (104): 30580-30587. Accessed via


1. The American Speech-Language-Hearing Association. (2005). Medicaid Coverage of Speech-Language Pathologists and Audiologists. Available online:

For More Information

• The American Speech-Language-Hearing Association, 800-498-2071, or online:

• Mark Kander, (301) 897-0139, e-mail:

• Lissa Power-deFur, PhD, (434) 395-2369, e-mail:

• Kathleen Whitmire, PhD, (301) 897-0137, e-mail:

Jason Mosheim is an Assistant Editor at ADVANCE. He can be reached at


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