Billing Medicaid raises many issues and concerns for school-based clinicians. When should Medicaid be billed for services? When are school-based services "educational" and when are they "medical"? Aren't school-based services already covered under the Individuals with Disabilities Education Act (IDEA)? What are the Medicaid rates?
50 States, 50 Programs
Established in 1965 under Title XIX of the Social Security Act, Medicaid provides medical assistance for low-income Americans. The federal government provides broad guidelines for administering Medicaid funds but, since Medicaid is a joint program between the federal and state governments, all 50 states implement Medicaid differently. Each state administers its program, establishing its own eligibility standards; determining the type, amount, duration, and scope of services; and setting the rate of payment for services.
Since 1988, Medicaid has been authorized by Congress to reimburse for IDEA-related, medically necessary services, including speech-language pathology and audiology services. In these cases, funds from Medicaid are to be used prior to IDEA funds. States also can obtain federal reimbursement for "administrative costs" associated with providing these services.
The Centers for Medicare and Medicaid Services (CMS) have not yet provided clear guidance about what comprises medically necessary services. Anything that impedes a child's participation in the school environment can be deemed "educational" and fall under IDEA, but ASHA maintains that any distinction between medical and educational speech-language pathology and audiology services is artificial. Children need to communicate around-the-clock, not just during school hours.
To Bill or Not to Bill?
Some states require that schools bill for Medicaid-eligible services. But in areas where such billing is optional, many school-based clinicians—already overwhelmed by paperwork—may question whether pursuing Medicaid reimbursement is worth the trouble.
In speech-language pathologist Roberta Kreb's home state of Minnesota, schools are required to bill Medicaid. But Kreb, an independent consultant with significant background in third-party reimbursement and state Medicaid, has some ideas about how school districts in states where billing is not mandatory might weigh their options.
"The greatest factors—positive and negative—related to third-party reimbursement are the district's budget and the need for revenue," she says. The need for funds "is usually the driving force for a district to start the process, combined with the number of children whose health care is covered by the state's Medicaid program."
To determine how many children may be Medicaid-eligible, districts look at the number of students on free or reduced lunches, as well as the number of students with severe physical and/or cognitive disabilities, Kreb points out.
"Another issue is clinicians' buy-in," she says, adding that although Medicaid billing does not require clinicians to serve their students differently, it does entail more—or a different type of—paperwork or documentation.
"SLPs should continue to provide the type and scope of services outlined on the student's IEP or IFSP," she says. "The added burden to the SLP may include more frequent progress notes and completing daily treatment notes along with a billing log.
"The billing process requires a higher level of accountability than some providers are used to," Kreb adds, pointing to the difference in funding programs. While schools have traditionally been entitlement programs, third-party billing moves special education services into a fee-for-service mode and, because the funding is federal, she notes, "The accountability requirements must be met."
To streamline Medicaid documentation and reduce the time required for accountability measures, Kreb suggests reviewing the district's processes and procedures to "identify holes in the system" that can be changed. Clinicians can use word-processing software to maintain data and reports, reducing redundancy in report writing and enhancing the ability to maintain objective data on students' progress.
Who Gets the Money?
According to the General Accounting Office, school districts that actively and ethically pursue Medicaid reimbursement report an average annual recovery of $2,000 per student. But even if Medicaid does reimburse for services, there is no guarantee that funds will be directed back to special education and not into the school's general fund.
For clinicians, successful Medicaid billing often entails not only time and paperwork, but also advocacy to ensure that reimbursed funds come back to the program and to the students.
Frank Bender, Oregon's State Education Advocacy Leader (SEAL), reports that SLPs in his district—Portland Public Schools, the largest district in the state—are billing for Medicaid and are seeing at least some of the funds returned to special education.
Although a majority of the reimbursed Medicaid funds go into the district's general fund, he says, "Special education also receives a portion of the money—which is nice since we are generating all of the money."
With that money, the Portland district's special education department has been able to purchase technology and test batteries for specialists—school psychologists, SLPs, occupational therapists, and physical therapists.
"We also have a handful of specialist positions that are funded primarily from Medicaid dollars," Bender adds. "It's my understanding that our district funds at least two SLP positions with this revenue. Without these funds, SLPs' caseloads—which average between 50–55—would be higher."
Smaller districts may not be as aggressive in using Medicaid funds, Bender believes. "It could be that the number of eligible students wouldn't equal the amount of money spent to set up a system to track the Medicaid billing process," he says.
For clinicians who are billing Medicaid but not seeing any funds returned to their programs, Kreb recommends strengthening their advocacy efforts with hard data. "Clinicians need to use data to make their case in these situations," she says. "Knowing the dollars generated and students served, and relating that to the costs of billing, makes a strong case for revenue to be returned."
Treatment outcome data from ASHA's National Outcomes Measurement System (NOMS) can also be useful, says Kreb, in advocating for intensive speech-language pathology services for a shorter period of time, as opposed to services provided once or twice a week for many years. "NOMS provides cost-effective data regarding the frequency and duration of treatment," she says.