Insurance Reimbursement

When a child is in need of Speech, Occupational and Physical Therapies there are often several options that are available to parents when seeking services. Both, early intervention agencies (services at reduced cost) and school systems (services free of charge) provide speech language therapy services to children who qualify under a set of federal regulations and state education laws. Many hospitals also provide outpatient speech language services to children, though each facility has its own regulations regarding service provision, which may be significantly restricted.

To qualify for early intervention services, a child must be from 0-3 years of age. They must also present with a 33% delay {percentage subject to change} (as per standardized testing) in one developmental area of functioning (e.g., speech and language) or a 25% {percentage subject to change} delay in two or more developmental areas of functioning (e.g., cognitive and social emotional) in order to be picked up for therapy by an early intervention agency in your area. Even if children do qualify for speech services they may be placed on a waiting list if the agency is a very busy one or if they experience a shortage of speech language pathologists at that particular time.

In the school setting in order for the child (pre-K and up) to receive speech and language services they must be classified. This involves creating a “label” which translates into an “explanation” for the child’s speech and language difficulty. The severity of speech and language delay as well as overall functioning of the child will typically determine the “type of classification” the child will receive (e.g., in NJ if the child has a speech and language deficit only they may be classified as “Communication Impaired”). Unfortunately the vast majority of school districts require for the child to have a specific classification in order to be eligible for speech language therapy or any other special education services. Of course, during the course of therapy the child can be reclassified or even declassified depending on their progress and gains. However, some parents may not be happy with their child receiving a negative academic label due to a concern on how that label will affect their child’s future academic opportunities. As a result they may seek private therapy in order to keep their options open.

There are also many instances when the child may not be eligible for therapy services despite the display of an obvious speech and language deficits on their part. For example, their deficit may not be “great enough” to qualify them for services. In other instances, the child might qualify for services but the frequency may not be satisfactory to the parent (the child might get only one group therapy session and the parent feels they need 2 or 3 individual sessions).

As a result of the above, many parents often choose to pursue the services of a private speech and language therapist in order to either set up treatment or to supplement their child’s existing therapy sessions. Many of them choose to do it because supplemental therapy can often reduce the time children spend in treatment.

However, when families seek supplemental services from their health plan, they often discover that the majority of private health plans will not pay for the exact same services that are provided in early intervention or school settings. That is because unlike other therapies (e.g. physical therapy), whose sessions may be completely covered by your insurance, speech therapy is a whole other ball game. Consequently, below are some explanations of what speech therapy services your insurance may actually cover.

Assessment Coverage
Typically, parents don’t usually seek out speech language pathologists before consulting with other relevant professionals such as pediatricians and child psychologists. In the majority of cases it is usually the pediatrician who gives a referral for speech therapy services or at least for a speech language assessment.

It is important to note that most insurance policies will cover (partially or completely) initial speech and language evaluations even if the speech therapist is out of network. The first step is to call your insurance company and ask them what documentation is required to get assessment coverage. Here, depending on your insurance company, responses might vary. Some insurance companies require a written prescription from the doctor coupled with the precertification interview with the treating speech therapist. Typically the utilization management section of the insurance company deals with the precertification interview. After precertification takes place, make sure to ask your insurance representative regarding the coverage for the out of network therapists. Please note that many private practitioners don’t accept insurance. They will instead provide you with a letter for your insurance company, containing the necessary diagnosis and treatment codes, incurred fees as well as a brief description of services provided, and will expect you to apply for reimbursement on your own.

Note: Parents should not assume that if assessment is provided in an outpatient hospital setting their health insurance will pay the bill. In many cases insurance denials result in the parents having to pay the full cost of the services provided. Hospital services can be very expensive. Assessments at hospitals vary from $260 to $1200 depending on the type and comprehensiveness of an assessment provided. Consequently, even if you do decide to seek assessment services from an outpatient hospital setting, you still need to check with your insurance company to make sure that this service will be covered.

The first step to insurance coverage for assessment is to speak to the insurance representative directly, even if your service provider had already done so for you. Parents are encouraged to do the above in order to avoid any misunderstanding and confusion, which may lead to costly errors. Just asking if you are covered for “speech” therapy is not enough to determine if you are covered for the specific treatment you need. Therefore, when asking about coverage, you want to ask which diagnostic and procedure codes your speech therapist should use to help assure the codes used accurately reflect the coverage you have. It is always better to learn and clearly understand information firsthand rather than from a third party, especially because the same coverage that pays for assessment may not cover therapy services: a fact that baffles and outrages many of the parents.

To reduce confusion, take detailed notes during all conversations with the insurance company. You may get conflicting information from different people at the insurance company and it will be important for you to write everything down as you move through this process. Always write down the date and time of your phone calls, as well as the name, phone number and department of the person you’re speaking with and their exact response to your question.

Therapy coverage
The truth is that most commercial health insurance speech therapy coverage is very limited for pediatric speech-language pathology services. Many policies exclude children by age (e.g., all children under 6) from coverage. Others 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 state that they will pay for treatment of problems related to medical conditions, but will not pay for autism or developmental delays (e.g. late talkers, articulation deficits). MOST POLICIES DO NOT COVER DEVELOPMENTAL SPEECH THERAPY SERVICES.

A research of a few selected major insurance companies (e.g., Cigna, Aetna, Blue Cross, United Healthcare etc) yielded the following results in regards to coverage for speech therapy services:

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: Limited to a 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.

Some insurance companies tend to explicitly specify exclusions to services. For example, here is an excerpt taken directly from the Blue Cross Blue Shield of Rhode Island website regarding speech therapy services: “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.”

However others do not explicitly state what kind of conditions will be excluded from coverage. For instance, your benefit’s handbook may state that speech therapy is a covered service; however, your plan may deny reimbursement for services based on your child’s diagnosis. Diagnoses that may be excluded from coverage include:• Apraxia

  • • Autism
  • • Central Auditory Processing
  • • Congenital Disorder (i.e. Cleft Lip & Palate)
  • • Developmental Delay
  • • Mental Retardation
  • • Language Disorder
  • • Stuttering (Fluency)

When parents call the insurance company regarding coverage of therapy services, there are several important questions they need to ask:

    • 1. My child is ____old. Does our policy cover his speech services?
    • 2. What conditions will insurance specifically cover?
    • 3. What ICD-9 (diagnosis) codes and CPT (treatment) codes are covered for reimbursement?
    • 4. Do I need to obtain a prescription for therapy services?
    • 5. Do I need to obtain precertification for therapy services?
    • 6. Which conditions are specifically excluded from treatment?
    • 7. How many sessions will insurance cover? Is there a time limit?
    • 8. Do I have a deductible or co-pay?
    • 9. Do I need to schedule all of the visits by a certain date?
    • 10. Does insurance cover out of network therapy services?
    11. How do I get reimbursed for out of pocket therapy expenses? What do I need to provide the insurance company with?

Speech Language Services and diagnosis of Autism
It is important to note that when seeking speech language services for children diagnosed with Autism Spectrum Disorders (e.g., PDD, Asperger’s etc) there are 17 states that provide insurance coverage (California, Connecticut, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Montana, New Hampshire, New Jersey, New York, Tennessee, and Virginia). Of these, 10 provide coverage for autism through their laws mandating coverage for mental illness (California, Illinois, Iowa, Kansas, Louisiana, Maine, Montana, New Hampshire, New Jersey, and Virginia). The other six states have specific laws regarding insurance coverage for autism (Georgia, Indiana, Kentucky, Maryland, New York, and Tennessee), which you can find directly in the policy.

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. And the fact is that most people don’t do it because it’s a time consuming hassle. Along the way, 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.

Now that we have gone over the insurance process in some detail, please keep in mind that you can always learn more information on this and any other speech pathology related topic by visiting the ASHA website and clicking on the ‘Public’ tab located on the left side of the screen.

Selected References
1.http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0177_coveragepositioncriteria_speech_therapy.pdf
2. http://www.cga.ct.gov/2006/rpt/2006-R-0793.htm
3. http://www.insurancehelpforautism.com/insuranceletter
4. http://www.aetna.com/cpb/medical/data/200_299/0243
5. http://www.stutteringhelp.org/Default.aspx?tabid=71
6. http://www.asha.org/public/outreach/take-action/sample-apraxia.htm
7. https://www.oxhp.com/secure/policy/outpatient_speech_therapy_1208
8. https://www.bcbsri.com/BCBSRIWeb/plansandservices/services/medical_policies/SpeechTherapy.jsp
9. http://www.ican-online.org/advocacy/filing-insurance-complaint
10.http://www.smartspeechtherapy.com/speech-language-services-and-insurance-coverage-what-parents-need-to-know/

Information provided is based on online resources and websites. The information provided is intended as a resource. Each state has adopted a different standard and policy for testing and a different percentage for meeting the requirements for services in a school based setting and for state funded services. Specific information, percentages and criteria is subject to change and IT4K, Inc is not responsible for any errors or misinformation.

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