Speech Language Services and Insurance

Insurance Coverage of Speech Pathology Services: What Parents Need to Know

Created by Tatyana Elleseff MA CCC-SLP Smart Speech Therapy LLC For Individual Use Only Do not resell, copy, or share downloads. Do not remove copyright

Overview

 This presentation provides basic information regarding insurance coverage for common outpatient speech language assessment and therapy services.  It contains important questions parents must ask when speaking to their insurance representatives regarding service coverage.  It provides common ICD-9 and ICD-10 pediatric diagnostic codes, lists common SLP-based therapeutic (CPT) codes and discusses common service exclusions in private large insurance policies.  It also provides some suggestions on how to initiate appeals for denial of services and includes links to helpful resources parents can access to obtain further elaboration on the information provided in this presentation.

Intended Audience

 Parents  Caregivers  Speech Language Pathologists (SLPs)  New Graduates  Clinical Fellows  Private Practitioners  SLPs may forward this presentation to the parents seeking clarification on reimbursement questions

Disclaimer

 The above information was gathered on the East Coast and is applicable primarily to the states located in that area  This information is by no means an exhaustive treatise but is meant to serve as a very general guideline for parents seeking more information regarding speech therapy insurance reimbursement

Overview of therapy services provided by the state  Early Intervention 0-3  Pros  Reduced cost  Cons  33% delay in 1 area of functioning  25% delay in 2 areas of functioning  Child may not qualify for services based on above but still have significant difficulty  Long wait times  School Based 3+ years of age  Pros  Free  Cons  Classification Needed  Parents may not be happy with frequency/group composition/duration

Who does NOT Qualify for Early Intervention Services

 The following are the circumstances in which SLP services will be denied and a Developmental Interventionist (DI) will be assigned to work with the child instead (vs. in conjunction with SLP) in the state of NJ (rules are similar in many other states)  If a child, under 28 months of age, presents with a “late-talker profile” (pg 27)  If child with speech-language delays also has delayed prelinguistic skills (e.g., joint attention, turn-taking, etc), the DI will work with the child first to establish them (pg 29)  If a child under 28 months has expressive language delay only and has intact cognition, receptive language, and motor skills  If the child has a cognitive delay commensurate with a receptive and expressive delay (p 30)  If a child has a hearing impairment and no other developmental delays, DI services will be provided while information is being obtained and medical intervention is being provided (pg 31) (Service Guidelines for Speech Therapy in Early Intervention www.nj.gov/health/fhs/eis/ )

Supplemental speech language services

 There are also many instances when the child may not be eligible for therapy services despite obvious speech-language deficits  Deficit may not be “significant” enough to qualify for services  Child may qualify for services but the frequency is insufficient/unsatisfactory (to the parent)  Get one group therapy session and the parent feels they need 2 or 3 individual sessions  Many parents often choose to pursue private services  Initiate therapy  To supplement existing therapy  Appropriate and relevant supplemental therapy can often reduce the time children spend in treatment

Initiating Assessment

 Initial assessment  Pediatrician referral?  Self-Initiated referral?  Evaluation may be partially covered even for out of network providers  Call your insurance company to ask what documentation is needed  Prescription from pediatrician  Precertification interview with the treating speech therapist?  After precertification is finished ask about out of network coverage  Many private practitioners don’t accept insurance  Provide invoice to parents  Diagnosis and treatment codes  Hours and fees  Description of services provided  Parent applies for reimbursement on their own WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#›

Say NO to Assumptions

 DON’T assume that if assessment is provided on an outpatient hospital basis health insurance will pay  Frequent insurance denials result in parents paying full cost of very services  Assessments at hospitals vary from $260 to $1200+ depending on the type and comprehensiveness of an assessment provided.  If you do decide to seek assessment services from a hospital check with your insurance company to make sure that this service will be covered

Calling the insurance company

 Don’t just ask if “speech therapy” is covered!  Determine if you are covered for the specific treatment you need!  Which diagnostic and procedure codes are covered?  Take detailed notes during all conversations with the insurance company.  You may get conflicting information from different people so it’s important to write everything down  Always write down  Date and time of your phone calls  Name, phone number and department  The representative’s exact response to your question

Therapy Coverage

 Most commercial health insurance speech therapy coverage is very limited for pediatric speech-language pathology services.  Many policies exclude children by age from coverage  All children under …  Some refuse to cover school age children because they specify that the child is expected to receive speech language services in school settings  Some policies exclude children with congenital conditions, regardless of the nature or severity  Other policies will pay for treatment of problems related to medical conditions, but will not pay for autism or developmental delays  Late talkers  Articulation deficits  MOST POLICIES DO NOT COVER DEVELOPMENTAL SPEECH THERAPY! WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#›

What do the major companies pay for?

 Aetna US Healthcare  Covers speech therapy for non-chronic conditions, illnesses, and injuries.  Limits treatment for a 60-day period per incident of illness or injury. Requires referral of PCP and prior approval by Aetna.  Blue Cross Blue Shield  Covers Outpatient short-term rehabilitation services for conditions which are expected to show significant improvement through short-term therapy, as determined by the PCP.  Limits: maximum of 30 visits per calendar year.  CIGNA / Healthsource  Covers: Conditions that are expected to show significant improvement within a 60-day period, as determined by CHCNC. Covered for correcting speech disorders that are the result of diagnosed medical illness, surgery, or accidents only.  United HealthCare  Covers: Short-term speech therapy provided under the direction of a participating provider.  Limits: Limited to 20 visits per member per calendar year. Requires prior approval. Inpatient services are covered under the medical inpatient benefits. Excludes: Speech therapy for children of school age as these services must be provided through the school system.

Specifying exclusions directly in the contract

 Blue Cross Blue Shield of Rhode Island  “Treatment of the following conditions is a contract exclusion: psychosocial speech delay, expressive language delay, behavioral problems (including impulsive behavior and impulsivity syndrome), attention disorders, conceptual handicap, mental retardation, autism, developmental delay (excluding BlueCHiP for RIte Care), stammering, or stuttering as treatment for these services are provided by the school department.”

Lack specification and …coverage

 Many insurances will not explicitly state what kind of conditions will be excluded from coverage  Benefit's handbook says speech therapy is covered but  Your plan may deny reimbursement for services based on the child's diagnosis  Common exclusions:  Child hood Apraxia of Speech  Autism  Central Auditory Processing  Congenital Disorder  Cleft Lip & Palate  Developmental Delay  Mental Retardation  Language Disorder  Stuttering  Fluency

Questions to ask your insurance:  What conditions will insurance specifically cover?  My child is ____old. Does our policy cover his speech-language services?  What ICD-10 (diagnosis) codes and CPT (treatment) codes are covered for reimbursement?  Do I need to obtain a prescription for therapy services?  Do I need to obtain precertification for therapy services?  Which conditions are specifically excluded from treatment?  How many sessions will insurance cover?  Is there a time limit?  Do I have a deductible or co-pay?  Do I need to schedule all of the visits by a certain date?  Does insurance cover out of network therapy services?  How do I get reimbursed for out of pocket therapy expenses?  What do I need to provide the insurance company with?

DSM-5 Changes SLP-Relevant Disorder Categories

 Intellectual disability (Intellectual developmental disorder)  Replaces the term “mental retardation” with “Intellectual disability (Intellectual developmental disorder).”  Relies more on adaptive functioning rather than on specific IQ scores.  Communication Disorders  Changed from expressive and mixed receptive-expressive language disorders to include:  language disorder  speech sound disorder  childhood-onset fluency disorder  social(pragmatic) communication disorder

DSM-5 Changes SLP-Relevant Disorder Categories

 Specific Learning Disorder  Combines diagnoses of reading disorder, disorder of written expression, mathematics disorders, and learning disorder not otherwise specified.  Recognizes the need to use a variety of culturally and linguistically appropriate assessment tools and strategies and does not require use of a standardized measure.  Does not include oral language.  No reference to modalities of language

DSM-5 and ICD-10 Changes

 Three DSM-5 conditions-language disorder, speech sound disorder and social communication disorder-have the same ICD-9 number: 315.39, "articulation, phonological disorder”  The corresponding codes in ICD-10 (which took effect Oct. 1, 2015), are differentiated to  Language disorder (F80.9)  Speech sound disorder (F80.0)  Social communication disorder (F80.89, "other developmental disorders of speech and language")  Childhood-onset fluency disorder is assigned 315.35 (ICD-9) and F80.81 (ICD-10) (see slide 20 for further details)

Divergent Coding in DSM-5

 “Social communication disorder," a code that does not appear in ICD  A person with a social communication disorder may have features of autism, but not enough to meet the new autism diagnostic standard.  Although ICD and DSM have always defined autism from slightly different perspectives, the result was usually reasonably consistent.  The new social communication disorder definition, however, does not align with ICD  http://www.asha.org/uploadedFiles/ASHA/Publications/leader/2 013/130801/DSM-5-Chart.pdf

Common Pediatric Speech Language Codes

 ICD-9/ICD-10 Conversion  315.3/ F80.89 Other developmental disorders of speech and language  315.31/F80.1 Expressive language disorder  315.32/F80.2 Mixed receptive‐expressive language disorder  H93.25 - Central auditory processing disorder  315.34/F80.4 Speech and language developmental delay due to hearing loss  315.35/F80.81 Childhood onset fluency disorder  Cluttering NOS  Stuttering NOS  315.39/F80.89 Developmental articulation disorder  Dyslalia/Lisp  F80.0 Phonological disorder  313.23/ F94.0 Selective Mutism  388.45/ H93.299 Acquired auditory processing disorder  784.69/ R48.2/ R48.8 Childhood Apraxia of Speech

2014 Therapy Treatment (CPT) Codes

 92521  Evaluation of speech fluency (e.g., stuttering, cluttering)  92522  Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria);  92523  Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)  92524  Behavioral and qualitative analysis of voice and resonance  92507  Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual

Intellectual Disabilities and Syndrome Codes

 ICD-9/ICD-10  317.0/ F70 Mild intellectual disabilities  318.0/ F71 Moderate intellectual disabilities  318.1/F72 Severe intellectual disabilities  318.2/F73 Profound intellectual disabilities  319/F78 Other intellectual disabilities  319/F79 Unspecified intellectual disabilities  330.8/F84.2 Rett Syndrome  758.0/ Q90.9 Down Syndrome  758.7/ Q98.4 Klinefelter Syndrome  759.81/ Q87.1 Prader-Willi Syndrome  759.83/Q99.2 Fragile X Syndrome

Autism Codes

 Autism spectrum disorder (ASD)  Eliminates pervasive developmental disorder and its subcategories (autistic disorder, Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder, pervasive developmental disorder-not otherwise specified).  Instead, children meeting the criteria will be given a diagnosis of “autism spectrum disorder” with varying degrees of severity.  Omits criterion related to the development of spoken language  ICD-9/ICD-10  299.0/ F84.0 Autistic disorder (infantile)  F84.5 Asperger Syndrome  299.1/F84.3 Childhood disintegrative psychosis  299.8/ F84.8 Other specified pervasive developmental disorders  F84.9 Pervasive developmental disorder, unspecified

Speech Language Services and Autism

 States with Specific Autism Mandates Alabama Kansas New York Alaska Kentucky Oregon Arizona Louisiana Pennsylvania Arkansas Maine Rhode Island California Massachusetts South Carolina Colorado Michigan Texas Connecticut Missouri Vermont Delaware Montana Virginia Florida Nevada West Viriginia Illinois New Hampshire Wisconsin Indiana New Jersey Iowa New Mexico http://www.asha.org/Advocacy/state/States -Specific-Autism-Mandates/

Please note that out of these a number of states provide coverage for autism through their laws mandating coverage for mental illness (see slide 15 for further details)

Speech Language Services and Autism (cont)

 States with Limited Autism Mandates  http://www.asha.org/Advocacy/state/States-Limited-Autism- Mandates/  District of Columbia  Georgia  Maryland  Oklahoma  Tennessee

States with Mental Health Parity for Autism

 Hawaii  Minnesota  Mississippi  Nebraska  North Carolina  North Dakota  Ohio  Utah  Washington  http://www.asha.org/Advocacy/state/States-Mental-Health- Parity-Autism/

States with no Autism Therapy Coverage

 Below states do not have  Specific insurance coverage mandates for autism spectrum disorder  Mental health parity law or  Mental health parity law does not include autism spectrum disorder as a covered mental illness  South Dakota (not included)  Wyoming (no parity)

Speech Language Services and Autism (New Jersey)

 Requires specified health insurance policies and health benefit plans to provide benefits for treatment of autism or other developmental disability. Coverage shall include:  Medically necessary (as prescribed through a treatment plan)  Occupational therapy  Physical therapy  Speech therapy  The maximum benefit amount for a covered person in any calendar year through 2012 shall be $37,080.  Citation: N.J. Rev. Stat. §17:48-6ii; §17:48A-7ff; 17B:26-2.1cc; 17B:27-46.1ii; 17B:27A-7.16; 17B:27A-19.20; §26-2J-4.34; §52:14-17.29p; 52:14-17.46.6b

Denials and Appeals

 If you have the speech therapy benefits and the coverage for your child's speech and language therapy is denied, always ask for the denial in writing and try to appeal the decision using the proper appeal procedure within your insurance company.  Insurance companies count on consumers not appealing decisions. Most people don't appeal because it’s a time consuming hassle.  Document all conversations with insurance representatives. Documentation can be very helpful for an appeal.  In some states, even if you have exhausted appeal procedures within your insurance company, you can appeal to your state's insurance commission, some of which allow for the filing of complaints online.

Helpful Resources

 ICD-9-CM to ICD-10-CM Free Conversion Tool  http://www.icd10data.com/Convert  2015 ICD-10-CM Diagnosis Codes Related to Speech, Language, and Swallowing Disorder  http://www.asha.org/uploadedFiles/ICD-10-Codes-SLP.pdf  Making sense of your health insurance plan: speech language and hearing benefits  http://www.asha.org/uploadedFiles/public/add-benefits/HealthInsBrochure.pdf  Employer Insurance Packet  Tools to help consumers with changing health plans to include coverage of speech, language, and hearing services  http://www.asha.org/public/coverage/employer_packet.htm  Appealing Denials  http://www.asha.org/practice/reimbursement/private-plans/appeals.htm  Additional Insurance Tips when Appealing Speech Treatment Denials  http://intermountainhealthcare.org/services/pediatricrehab/Documents/InsuranceTipsforFamilies %20-%20Speech%20Therapy%20Considerations[1].pdf  Treatment Efficacy Summaries  http://www.asha.org/public/EfficacySummaries.htm  Establishing Medical Necessity for Speech Language Services  http://www.asha.org/uploadedFiles/practice/reimbursement/mednecfifinal3.pdf

Helpful Resource Bundles

 The Checklists Bundle  General Assessment and Treatment Start Up Bundle  Fetal Alcohol Spectrum Disorders Assessment and Treatment Bundle  Multicultural Assessment Bundle  Narrative Assessment and Treatment Bundle  Introduction to Prevalent Disorders Bundle  Social Pragmatic Assessment and Treatment Bundle  Psychiatric Disorders Bundle

Helpful Resources  Assessment Checklist for Preschool Aged Children  Assessment Checklist for School Aged Children  Speech Language Assessment Checklist for Adolescents  Differential Diagnosis of ADHD in Speech Language Pathology  Creating Functional Therapy Plan  Selecting Clinical Materials for Pediatric Therapy  Social Pragmatic Deficits Checklist for Preschool Children  Social Pragmatic Deficits Checklist for School Aged Children  Auditory Processing Deficits Checklist for School Aged Children

More Helpful Resources  Fetal Alcohol Spectrum Disorder An Overview of Deficits  Speech Language Assessment and Treatment of Children with Alcohol Related Disorders  The Role of Frontal Lobe in Speech and Language Functions  Executive Function Impairments and At Risk Pediatric Populations  Behavior Management Strategies for Speech Language Pathologists  Narrative Assessment of Preschool and School Aged Children  Treatment of Social Pragmatic Deficits in School Aged Children

Contact Information: Tatyana Elleseff MA CCC-SLP

 Website: www.smartspeechtherapy.com  Blog: www.smartspeechtherapy.com/blog/  Shop: http://www.smartspeechtherapy.com/shop/  Facebook: www.facebook.com/SmartSpeechTherapyLlc  Twitter: https://twitter.com/SmartSPTherapy  Pinterest: http://pinterest.com/elleseff/  Email: [email protected]