Challenges of a University Speech and Hearing Clinic
Fees and Reimbursement in 2012
Stuart Trembath, MA, CCC-A
Chair, ASHA Health Care Economics Committee
There are countless challenges in the education of speech-language pathologists and audiologists. Because clinical training is such an integral part of the graduate programs for our professions, the operation of the university speech and hearing clinic is of paramount importance. Clinical opportunities must match the readiness of the student and interface with the ongoing course work in the classroom. Adding to this challenge is the need to give the student broad clinical exposure and provide necessary experience as the student's ability to work independently increases. Given our role in health care, we are compelled to teach and implement evidence-based practices. Additionally, the importance of collecting data to enhance evidence-based practice should be included in the curriculum. Finally, graduating clinicians need to understand issues related to fees and reimbursement.
Once upon a time, the university speech and hearing clinic was solely a training ground for future clinicians. Financing a clinic was part of the cost of graduate training. Clients who showed no significant improvement in function were encouraged to continue clinic services so that students could obtain needed evaluation and treatment experiences. Little thought was given to generating revenue; in some cases, the clinic was seen as a "loss leader." Consequently, charges for service were inconsistent or nonexistent. As a result, students learned little about Common Procedural Terminology (CPT) codes and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, including specific coding and reimbursement instructional modules, CPT codes, ICD-9-CM, and Health Insurance Portability and Accountability Act of 1996 [HIPAA]. Moreover, privacy and security of electronic billing and clinical records are essential for all programs under HIPAA. Clinicians began their careers with little, if any, understanding of how to ensure compliance with federal and state regulations.
In 2012, the isolated clinic model for university speech and hearing clinics is outdated. The evolution of this model reflects the university's need to generate revenue so that clinics can become self-supporting. Some university clinics may no longer incorporate clinic expenses into tuition charges. Clinic directors and program chairs have had to explore new ways to generate revenue. If clinics receive no support through university or training grants, where do program and clinic directors turn? Many are billing patients or their health insurance plans for services provided in the clinic, which contributes yet another level of complexity to student training (Kander, 2010).
As clinics move into the world of billing and reimbursement, many questions will need answers. The American Speech-Language-Hearing Association (ASHA) provides a comprehensive list of questions and answers on its website at Medicare and University Clinics Questions and Answers. Here are some additional questions for the reader's consideration:
- How much revenue is expected from the clinic?
- What will the sources of revenue be?
- What level of student supervision will be appropriate for these services?
- How does one establish a sliding fee schedule for low-income clients who do not have health plan coverage?
- What is required to bill private health insurance plans, Medicare, and Medicaid?
- With regard to setting fees for service, how much revenue is necessary to support the clinic?
- Will all of the revenue come from services provided by students, or will some of the revenue come from clinical supervisors' seeing clients without students?
- Do payers require services provided by licensed and certified speech-language pathologists and audiologists?
- What role does the supervised student have when a licensed and certified professional is required for service delivery?
Once the amount and sources of revenue have been determined, the department will need to have the process reviewed by the university administration. The Medicare Fee Schedule [PDF] is a good starting point for estimating the clinic fee structure. If the clinic will bill third-party payers, Medicare and Medicaid laws, regulations, and guidelines will need to be reviewed to ensure compliance. When agreeing to work with third parties, you must negotiate contracts and adhere to rules and regulations. Some insurers will not require a contract; however, their rules for student services must be determined. Third-party billing raises more questions:
- How will training students meet the requirements necessary to bill these payers?
- How do you balance student growth and independence with the level of supervision necessary to bill Medicare and other third-party payers for services? For example, if adequate supervision is not possible, but the criteria for medical necessity for services have been met, should you provide services to Medicare patients or refer them to another clinic?
- If the decision is made to provide services to Medicare patients, you will also need to be prepared to use advance beneficiary notices of noncoverage (ABNs). An ABN is used to notify a patient when Medicare is unlikely to reimburse for a particular procedure; the ABN allows the patient to decide whether to obtain a service that must be paid "out of pocket."
- What mechanisms are in place to ensure that billing practices for all patients will be consistent and transparent?
- Are all billing charges justified by the documentation of the visit?
Documentation of Services
As part of the clinical education, students must document all patient interactions. Proper documentation requires the following elements:
- Billing codes (ICD and CPT) must match documentation.
- Documentation must support the scope and level of service (complexity or time).
- CPT codes must be appropriate for diagnostic codes (ICD codes).
- Coding and billing for services must be performed by eligible practitioners for eligible patients.
One must remember that, upon medical review, inadequate/incomplete documentation may result in denial of claims.
For speech-language pathology, Medicare requires that therapy services be of appropriate type, frequency, intensity, and duration for the individual needs of the patient. Consequently, documentation should establish:
- variables that influence the patient's condition.
- objective measurements of progress toward goals.
To do this, documentation should include:
- Plan of Care/Certification of Plan of Care
- Progress Reports
- Treatment Notes
- Discharge Note
(Medicare Benefit Policy Manual Publication, 100-02, Chapter 15, Section 220.3 [PDF])
For audiology, proper documentation includes:
- Establishing medical necessity for the evaluation (i.e., appropriate medical history and referring physician)
- Written summary of test results
- Interpretation of test results
The report must be signed by the clinician and dated.
Changes in clinical training models mean students will need to be prepared to meet the requirements for coding and billing for the services that they provide. For instance, are CPT and ICD-9-CM codes currently included in clinical course work (e.g., for fluency or hearing evaluations)? Many tools are available to help students understand coding and reimbursement. ASHA committee/board groups on health care economics, school finance, and government and public policy collaborated to develop a resource—ASHA's Coding, Reimbursement, and Advocacy Modules—to help faculty and clinic supervisors teach students the basics of reimbursement principles and advocacy approaches, including documentation for third-party payers. Another ASHA resource, Medicare Rules and University Clinics, provides basic information in two tables that explain Medicare rules and how university clinics can comply with them.
What the Future Holds
Looking ahead, we in speech-language pathology and audiology face new challenges in university clinics and programs. Officials at the Centers for Medicare and Medicaid Services are using terminology such as episodic payment systems, and they have initiated pilot payment programs for diabetes and cardiac care. Therapy services may soon see payment systems "bundled" for services, such as stroke rehabilitation or hearing loss care, demanding certain outcomes for payment. Our professions need to find ways to document our value by showing that our services make a difference in the everyday functioning of our patients. Our future will depend upon our ability to more efficiently provide services that result in very high functional outcomes. Our survival as professions will depend upon research and service delivery that empirically demonstrate the value of what we do.
To prepare for the many expected changes in health care economics, ASHA is sponsoring a "Summit on the Changing Health Care Landscape" in October 2012 at the National Office in Rockville, Maryland. This summit will bring together clinicians, researchers, university program heads, and governmental affairs experts from all areas of speech-language pathology and audiology to discuss and make recommendations on how we need to change to remain relevant as professions into the 21st century. The summit is via invitation but the outcomes will be shared with members.
ASHA. (2012). Medicare and university clinics questions and answers. Available from www.asha.org/Practice/reimbursement/medicare/SLPPrivatePractUniversityQandA/.
ASHA. (2012). Medicare and university or college clinics: Issues related to audiology and speech-language pathology services. Available from www.asha.org/Practice/reimbursement/medicare/Medicare-and-University-Clinics/.
Kander, M. (2010, August 31). Medicare rules and university clinics. The ASHA Leader. Available from http://leader.pubs.asha.org/article.aspx?articleid=2291838.
This article first appeared in the August 2012 issue of Access Academics and Research.