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Insurance Reimbursement Issues for Private Practice SLPs by Campbell, Krafcheck, & Samfield

Thursday 1:30 - 3:00 pm


Presented by: Lauralee Campbell, Debbie Krafcheck & Barbara Samfield

TSHA Annual Convention San Antonio, Texas February 21-23, 2008

Verifying Benefits Patient Health Information Needed

Patient's name & birthdate Insured member's name, birthdate, & social security number Plan name & plan number Insured member's ID number Insurance telephone number for providers

Questions to Ask Insurance Company

What are speech therapy benefits? What is the copay / coinsurance? What is the deductible? Are there any limitations? (i.e. # of sessions, medical necessity) Is a referral needed? Is pre-certification needed? Is plan fully insured (fully funded) or self-funded?


Insurance Reimbursement Issues for Private Practice SLPs by Campbell, Krafcheck, & Samfield

Thursday 1:30 - 3:00 pm

In-Network vs Out-of-Network Providers

In-Network Provider: Has contract w / ins company Provides services at "negotiated" rate Out-of-Network Provider: Does NOT have contract w / ins company Services typically not covered by HMO plans Network Insufficiency: No network provider w /in specific geographical distance Ins should pay at in-network benefit level Provider does NOT have to accept "negotiated" rate

Negotiated Rates

Definition: SLP contracts w /ins companies & receives pmts based on negotiated fee schedule Fee Schedule: varies according to managed care system (i.e., HMO, PPO) Negotiated Rate Reimbursement Options: Discounted fee-for-service: provider agrees to fees below normal rate (discounted fees) Capitation: ins pays provider "agreed" upon amount per month for all members requiring services Benefit: potential for increased patient caseload Rates: usually based on Medicare Fee Schedule Before Signing Contract: will fees meet your costs?

Fully Insured vs Self-Funded Private Health Plans

Types of Private Health Coverage: Fee-for-Service or Indemnity (Traditional) Ins policy only, sold only by ins companies Subject to Texas Dpt of Ins rules & state mandates Managed Care Sold by ins companies & HMOs Can be ins policy or self-funded health plan contract Types by Health Plan: Fully Insured or Fully Funded (Insurance Policy): Fee-for-service or managed care plans Policies for individuals or employer/assoc groups Regulated by TDI rules & state mandates Self-Funded Contract: Only managed care plans Only for large groups that can afford to pay claims Regulated by DOL


Insurance Reimbursement Issues for Private Practice SLPs by Campbell, Krafcheck, & Samfield

Thursday 1:30 - 3:00 pm

Fully Insured or Fully Funded Insurance Plan

Definition: ins policy underwritten by ins carrier for Texas residents & must comply w/state laws & ins rules Participation: small employers, few large employers Payout: employers pay premiums and insurers pay claims from pool of premiums Types of health plans: fee-for-service and managed care Consumers: most pay copays, co-insurance after deductible Regulated: state insurance rules, state mandates* *Texas Attorney General Ruling of 1987 & Mandated Offers apply ( Benefits: comprehensive or selective SB 418: applies to provider contracts entered or renewed after 8/16/2003 for these plans

Self-Funded Plans (ERISA Plans)

Definition: written contract for health benefits between employer and health plan provider, NOT ins policy, multi-state Participation: mostly large employers Payout: employers pay claims out of company assets Types of health plans: managed care plans only Consumers: pay deductibles, co-pays, and / or coinsurance Regulated By: US Dept of Labor, ERISA Laws Disputes handled by DOL Employee Benefits Security Admin (EBSA), call (214) 767-6831 Benefits: usually selective, often restrictive SB 418: does not apply to these plans

Model Speech and Language Benefits Plan (ASHA, 2008)

Assessment & Treatment

Full coverage: for pediatric & adult populations for all medical diagnoses that have ICD-9-CM code Treatment: must show measurable & positive functional change over reasonable time period Use of CPT Codes: 92506, 92507, 92610, 92526, & others listed on ASHA website


Coverage: for AAC and prosthetic devices and accessories Full Coverage: if recommended by ASHA certified and/or licensed SLP Device codes: listed on ASHA website


Insurance Reimbursement Issues for Private Practice SLPs by Campbell, Krafcheck, & Samfield

Thursday 1:30 - 3:00 pm

Texas Insurance Mandates

Mandates: Definition: Laws passed by State Legislature & signed into law by Texas Governor Enforcement: Texas Insurance Commission (formerly State Board of Insurance) Regulate: Ins carriers offering ins policies to residents Health ins policies offered to residents HMOs & some aspects of HMO health plans available to residents Interpretation of Mandates: Texas Atty General & Ins Commissioner Apply to ins policies only, not self-funded contracts

Texas Insurance Mandates

"Texas State Mandate" of 1987 (Op. #JM-612):

TX AG Jim Mattox asked to define phrase "alternate level of benefits" in Ins Code Coverage cannot be selective for sp & hrng benefits Speech & hearing mandated offer/ added "or alternative level of benefits negotiated" effective 4/1/05 (TIC Ch. 1365.0031365.004)

Recent Legislation:

Managed Care and Consumer Protection (1997): safeguards, UR, HMO liability Prompt Pay (1999): clean claims Prompt Pay (2001): prompt pay rules SB 418 (2003): clean claims, prompt pay, written verification, late payment penalties, ID cards, technical advisory committee for claims processing

Texas Ins Code Updates:

Telemedicine-telehealth /mandated benefit coverage (TIC Ch.1455.004) Therapies for children with dev delays /(TIC Art 21.53F, Ch. 9)

ICD and CPT Codes

ICD ­ International Classification of Diseases, 9th Edition (ICD-9-CM) Diagnoses patient's condition ­ be ready to support code Code to the highest available number in code (3, 4, or 5 digits) CPT ­ Current Procedural Terminology, 4th Edition (CPT) Service or procedure performed (evaluation, treatment) Use terms "evaluation, diagnosis, treatment" (not "therapy") Most common codes used by SLPs: See codes listed on ASHA website (


Insurance Reimbursement Issues for Private Practice SLPs by Campbell, Krafcheck, & Samfield

Thursday 1:30 - 3:00 pm

Denials and Appeals

Reasons for Denials Not covered benefit Not medically necessary Definition Contract: see what definition is given for medical necessity Texas State Attorney General Opinion: only in group ins plans "Developmental delays" not covered ("will improve with time with or without treatment") Treatment educational vs rehabilitative Treatment habilitative vs rehabilitative (does not restore previously possessed function)

Appeals Process Initiated by: patient or provider Outcome: often favorable Request: copy of denial in writing Expect: appeal may go to several levels After exhausted appeals: then file complaints by: Provider or patient w/ TX Ins Commission (group ins plans) Patient responsibility w/US Dept of Labor (self-funded plans) Sending documentation: use certified mail keep copies of all documentation send copies to TX Ins Commission (group ins plans only)

Not Medically Necessary

Request: data needed to prove medical necessity Obtain: letter of medical necessity from physician Documentation:

Tie to illness, congenital disorder or accident Document in diagnostic rpt or get medical records

Determine: if prior treatment was covered by ins (a different ins company or same company for earlier dates of service) Appeal Review: request an SLP be involved in review


Insurance Reimbursement Issues for Private Practice SLPs by Campbell, Krafcheck, & Samfield

Thursday 1:30 - 3:00 pm

Developmental Delays

Academic literature: uses "developmental" term to differentiate conditions in children versus adults US government definition of "developmental disability": Must have mental and/or physical impairment Manifests before individual is 22 years old Likely indefinite continuation Limitation or disruption of 3 or more major life activities Lifelong or extended duration for special services & supports Individuals with neurological disorders: Delayed development common

Educational vs Rehabilitative

IDEA: Schools responsible for educational needs Medical community (SLPs) responsible for medical needs of children School's responsibility: not concern of ins company Medical provider: not an educational institution

Habilitative vs Rehabilitative

Speech and language skills: Not limited to vocal expression Foundations of speech being developed before child is born or begins to talk HCFA's interpretation of the US fed provision: Includes "habilitation" services under "rehabilitation services" Provide documentation: Show why habilitative services should be covered when rehabilitative services are covered Documentation could include the US code "Rehabilitative" candidate: If patient has ability to develop speech and language skills


Insurance Reimbursement Issues for Private Practice SLPs by Campbell, Krafcheck, & Samfield

Thursday 1:30 - 3:00 pm

Medicare & Medicaid: Government Funded Health Coverage

Medicare: Definition / Funding / Administration Current: Prvt practitioners cannot bill Medicare directly Telemedicine/telehealth (still pending) Reimbursement: Rates set by Medicare Physicians Fee Schedule Private Health Ins & HMOs often use MPFS rates Changes in 2008 and future: Legislation to give SLPs supplier status & bill Medicare directly (prvt pract) Therapy cap extensions process to expire 6/30/08 10% across the board cuts in MPFS rates after 6/30/08


Medicaid: Tx Medicaid Health Program CHIP: Texas Health & Human Services Commission

SLPs in Private Practice & Medicaid:

Enroll as individual provider & obtain provider number

Non-school SHARS provider Private practitioner in THSteps-CCP (EPSDT)

Call NHIC at 1-800-925-9126 for application Fees based on Medicaid fee schedule

Rates much lower than Medicare Requirements

SLPs in Private Practice & CHIPs:

Join provider network in CSA (CHIP Service Area) Call CHIP at 1-877-KIDS NOW for information to enroll as provider Reimbursement info available from provider

Websites Am Assoc of Health Plans (main assoc of health plans, incl HMOs and PPOs) w/info on provider contracting relations & other issues from payer's perspective ASHA website w / info on billing and coding, Medicare, Medicaid, HIPPA, & payment policies that affect SLPs Texas Insurance Code Medicare & Medicaid (CMS) website w/ info on laws, regulations, and pmt policies related to federal payer programs ( which prvt payers often follow) Consumer health ins website w /gen info on appealing denials, health ins laws and basics of health ins


Insurance Reimbursement Issues for Private Practice SLPs by Campbell, Krafcheck, & Samfield

Thursday 1:30 - 3:00 pm

More Websites rance.html US Department of Labor / 1-866-4-USA-DOL Texas Medicaid Program

Texas State Attorney General Opinion Texas Dept of Ins / 1-800-252-3439 See Your Health Insurance, TDI (2004) for detailed explanation of health ins & applicable mandates / CHIP in Texas

Texas Medical Association / 1-800-880-1300 links to Ins Code & AG Opinion

ASHA & TSHA Publications

Appealing Health Plan Denials, ASHA (2002) Sample appeal letters included. Getting Your Services Covered, ASHA (2004) Guide to Texas Medicaid Programs Covering SLP Services, TSHA (2000) Negotiating Health Care Contracts and Calculating Fees: A Guide for Speech-Language Pathologists and Audiologists, ASHA (2004) National charge data


Bottom Line: "Insurance reimbursement issues remain costly & ongoing problem for SLP providers in private practice"


Lauralee Campbell ­ [email protected] Debbie Krafcheck ­ [email protected] Barbara Samfield ­ [email protected]




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