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 WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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. WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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 WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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 WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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 WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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/ ) WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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 WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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 WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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 WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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. WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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.” WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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 WWW.SMARTSPEECHTHERAPY.COM Copyright © 2013 Smart Speech Therapy LLC Page ‹#› 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?