Third Party Payor Systems as Systems of Change

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It’s ASHA season. That means I’ve been trying to cram in as much CEU credit as I can for the price of admission. There have been some amazing presentations. First, I’d like to say thank you to the presenters for their presentations and being willing to share their expertise and information. I made it a point to step outside of my comfort zone this year and I learned a tremendous amount that can be applied to my own work.

I’ve thought for a long time that we need to make sure CSD graduate students go through a “Professional Practices” class where we talk about the business of being a healthcare provider, above and beyond what is currently taught as part of a clinical methods course. I know why most universities don’t offer such a course. It’s because many in higher ed are removed from the business side of the field. But, students need to know the basics before they fledge and fly the university nest. I’m talking about making sure students know about CPT codes and ICD-10 codes and the basics of billing. Because, it’s getting to the point that SLPs’ lack of knowledge of these basic medical business concepts is hurting the profession.

How is that possible, you ask? Did you know that the communication and cognitive therapy services SLPs provide to patients with Parkinson’s disorder isn’t covered by Medicare? Why would that be? Because CMS (the boss of Medicare) bases funding decisions on the claims they receive. And, no category for reimbursement for those services was created because not enough SLPs knew to make sure the appropriate ICD-10 codes made it onto the billing claim forms. That’s how our ignorance hurts the profession! Because SLPs don’t know our own value, neither does anyone else. We don’t get invited to the table with PT & OT. And, like most other things in life, if we don’t take care of ourselves no one else will either.

There are a lot of changes happening on the adult side of the field as far as reimbursement practices. I don’t pretend to know or understand all of them, because I don’t work on the adult side. But, the takeaway from the excellent 2-hour presentation I attended were these: functional patient outcomes are the priority; quality and efficiency of services are paramount; and services are expected to be of relatively short duration. The expectation is that patients will be moved from the highest, most intense level of care to a level of care that allows them to stay at home, out of the hospital.

And, you know what they say: When Medicare catches cold, Medicaid and the private insurance companies catch pneumonia. These changes will be on the way for other third party payors. That’s why I attend workshops on changes about Medicare billing and funding.

It’s very possible that third party payors will help be an instrument of change. If Medicaid starts demanding more accountability in patient/client progress, then the field as a whole will need to move away from this idea of a ‘developmental sequence’ in therapy. By definition, a pediatric client who is in therapy is not developing typically. So, why do we try to impose the ‘normal’ developmental progression on our clients? Why do SLPs spend so much time on receptive language concerns when the family has explicitly expressed they are concerned with their child’s ability to express their needs and wants?

We know from actual, well-conducted studies in phonology that working on the later acquired, more complex sounds creates more change in the child’s system in a shorter amount of time. (Phonological processes were not based on research and lose out every time they’re compared to the complexity approaches.) We also know that working on morphology causes changes in a child’s speech sound development (cross-domain effects). I’ve extended this work with my own research, where I’ve found that targeting verb inversion in question formation and negation requires that children must acquire third person singular and regular past tense bound grammatical morphemes first.

Third party payors may be of huge benefit in terms of forcing clinicians to think about 1) what’s functional for their client; 2) what techniques will elicit those changes in the shortest amount of time; and 3) addressing the family’s concerns first. Focusing on following 2- to 3-step directions may be easier for the SLP. But, when the family’s concern is that the child can’t make choices between items or activities, then it makes no sense to work on following directions. That’s not functional for the family. Working on following directions gives the child no functional communication skill. In fact, in my opinion, working on goals like following directions promotes the dependence of the child on adults in their environment. Whereas, working on making choices verbally or through a choice board promotes the child’s independence in their environment. Working on making choices is more functional for the client and family and the outcomes more measurable for the clinician. Put another way, figuring out how to help a child express their needs and wants requires skilled intervention from an SLP. It takes our professional knowledge to determine at what level to start, the types of ‘errors’ we can expect to see and how to correct them, when to change prompting levels, and when to increase the complexity (e.g., from 2 units to 4 units). We can always recommend that teachers, paraprofessionals, and parents play modified Simon Says games.

Shifting to a model like those used in Medicare is going to require that SLPs have more knowledge of the business side of the field. We have to know how our claims are being billed. We have to know when they’re being paid and why. Conversely, we have to know why they are being denied. We have to make sure that information regarding diagnosis and severity is being coded correctly on the claims. We have to make sure that SLPs have a seat at the table when it comes to discussions of funding and funding mechanisms. We must make sure everyone on the team understands the value we provide to the patient’s/client’s care.

On the pediatric side of things, I think that means making sure school-based SLPs gently work to correct the perception that we’re “speech teachers.” In private practice, I think that means working to ensure that other professionals address us as speech-language pathologists. I’m not a “speech therapist.” That would mean working on solely articulation errors. That’s not what I do. I work to help children communicate optimally with their families as a speech-language pathologist. As the diagnosing clinician, it is my responsibility to make sure that the correct ICD-10 codes are filed on the billing claims and that I’m using all of the appropriate CPT codes available to me. For instance, if I’m teaching a client to access PECS or choice boards and teaching them to travel to a communication partner, I want to make sure I have authorization to bill CPT code 92606 for non-speech generating devices. I would code CPT 92507 for the language activity (e.g., making choices/expressing needs & wants) I used while I was teaching the access & use of PECS.

On the pediatric side of things, I think this means focusing more on the client’s outcomes rather than following an assumed developmental progression. If a child isn’t making progress in the first month or so, then it’s time to put the grad-school trained thinking cap back on and rethink what you’re doing with the client. Can you change the prompts? Do you need to think more top-down than bottom up (e.g., phonology)?

We need to be driven by these 3 questions: 1) Is it functional for the client?; 2) Is it measurable?; 3) Is it demonstrably working?

As always, thank you for reading. I look forward to your comments and observations.

For those of you who celebrate the holiday, wishing your family a Happy Thanksgiving.

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