Health insurers closely scrutinize claims for pediatric speech-language and hearing services to determine if coverage is available under a patient's policy. Plans often deny treatment for any of several reasons; clinicians can help their clients by understanding the possible reasons for denial and strategies to avoid them.
Health plans may deny treatment because:
- The services are not medically necessary.
- The service is not covered under the policy.
- Local public schools provide this treatment, and coverage is therefore excluded.
- The treatment is educational in nature.
- The treatment is for a developmental condition, which the health plan does not cover.
- The service is habilitative, and the plan covers only rehabilitative services.
Claims that are denied because the service is deemed not medically necessary are a frequent dispute for all types of health claim appeals. This type of dispute accounts for 37% of all appeals, but it also has the highest rate of overturn at 52% (Journal of the American Medical Association, February 2003). Speech-language pathologists and audiologists should emphasize that the service they are providing is medically necessary for the treatment of an impairment, and is not simply a quality-of-life issue. Speech-language pathology and audiology services improve health status and often treat conditions that have a neurological basis and result from injury, illness, or disease. Plans have different definitions for "medical necessity," but Medicare's definition represents an accepted standard—a service that is reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member (Medicare Benefit Policy Manual, Chapter 15, Section 220.2, "Reasonable and Necessary Outpatient Rehabilitation Therapy Services" [PDF]. Clinicians should document that their services focus on improvement of body functions (hearing, speech, swallowing, balance) and meet medical necessity.
Not a Covered Benefit
Sometimes the service clinicians provide is simply not a covered benefit. Examine the patient's policy for coverage terms. If the benefit is absent, focus on advocating for the employer and insurer to add the treatment to the health plan. For more on helping to improve health plan coverage of speech-language and hearing services, visit ASHA's Employer Insurance Packet Web site.
Health plans may deny treatment because the services are considered educational in nature. Clinicians can refer to the medical necessity arguments to address this denial, noting the services are provided for a medical or health-related condition. Further, the services are recognized as health services by Medicare, Medicaid, and The Joint Commission.
Health plans routinely deny coverage for treatment of developmental conditions. Aetna's Clinical Policy Bulletin: Speech Therapy (#0243), for example, notes: "Speech therapy for the treatment of delays in speech development (unless resulting from disease, injury, or congenital defect) is not covered under most traditional plans." Speech-language and hearing problems not linked to a medical condition often are assigned diagnostic codes from the 315 series under the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) that describe "specific delays in development." ICD-9 codes from the 784 series, on the other hand, describe speech-language and hearing impairments that are organic or neurologically based, and often establish medical necessity used for payment. Clinicians should make sure they are coding the condition correctly.
There has been some progress in gaining coverage for developmental conditions. The National Business Group on Health (NBGH), an organization representing large employers' perspective on national health policy issues, recommends "medical services for beneficiaries with speech-language and hearing disorders, and notes that services may be diagnostic, rehabilitative, or corrective in nature. Services may be used to help people develop skills inhibited by a problem present at birth or a developmental delay. Audiology services are defined as medical services specifically designed to address hearing loss, and include coverage of hearing aids." NBGH used ASHA's model benefit language to develop its recommendation.
If a government agency exclusion clause is written into a health policy contract, the health plan may send a child to the local public schools for speech-language and hearing services. ASHA is pushing for elimination of this exclusion in health care reform efforts and encourages members to take action at the state level and a advocate for removal of this exclusion from current health plan policies.
Rehabilitation vs. Habilitation
Health plans typically cover rehabilitation services, but not habilitation services. ASHA has addressed this issue by ensuring that the health care reform legislation signed into law in March mandates that rehabilitative and habilitative services must be included in health insurers' basic benefit package. ASHA members should monitor state health care reform activity to ensure such coverage language remains.
To improve health plan coverage for pediatric services, clinicians will want to continue to appeal claims when appropriate; educate payers, employers, and legislators about their services and the importance of coverage; be active in health care reform activity at the state and federal level; and encourage families of patients and consumers to ask health plans to cover pediatric speech-language and hearing services.