Speech-language pathologists in Tennessee have developed a manual on reimbursement issues related to autism services that could serve as a model for other states. The comprehensive guide, "Autism Equity Act Reference Manual," is freely downloadable from the Internet and answers a variety of questions about autism services and reimbursement.
The print version of the manual is 105 pages long, with information on audiology and speech-language services and CPT codes (Common Procedural Terminology, ©American Medical Association) for autism, co-occurring conditions and disorders, ASHA efficacy statements, provider types, treatment approaches, cognitive rehabilitation, and applied behavioral analysis, as well as the National Institutes of Health 2007 autism report.
Members of the Tennessee Association of Audiologists and Speech-Language Pathologists (TAASLP) created the manual after the state legislature passed a law in 2006 mandating health insurance coverage of autism services. TAASLP members realized that it would take time for insurers to understand fully the range of diagnoses, speech and language services, diagnosis codes, and treatment codes that providers would be submitting for reimbursement.
The manual was critical when the law took effect, according to Lynne Harmon, chair of the TAASLP Reimbursement Committee from 2005 to 2009. "Many insurance companies in the state had specifically excluded services for autism and therefore had no experience with autism spectrum disorders or the codes for the related services," Harmon said. "We were afraid that the medical directors of the insurance companies would be totally unfamiliar with what we provide. Plus, some companies that cover Tennessee residents are based in other states, and we wanted to make sure they all knew what the Act said."
In addition, Harmon explained, "many children with autism have other disorders, and we wanted to explain the different services these children might need."
The manual was a continuation of a collaborative effort that led to the passage of the Autism Equity Act, Harmon said. TAASLP worked with Tennessee chapters of the Autism Society of America, the Tennessee Disabilities Coalition, and families of children with disabilities to lobby for passage of the bill. The Tennessee autism mandate is limited: it considers autism a neurological disorder, requiring insurers that provide benefits for neurological disorders to provide benefits for the treatment of ASD at the same level as benefits for other neurological disorders; it applies only to children under 12 years old; and it does not apply to self-insured group arrangements.
TAASLP received grants from ASHA's State Advocates for Reimbursement program to help defray the cost of assembling, printing, and distributing the manual.
Compiling the manual was much easier than getting it into the hands of the key players, Harmon acknowleged. "We had no idea that getting the names of the insurance company medical directors was going to be so difficult. It seems that the companies don't want people to know who they are."
With the help of a contact in the state medical society, TAASLP was able to identify some—but not all—of the medical directors, but could not identify those located outside of Tennessee. The largest insurer in the state, Blue Cross/Blue Shield, would not respond to TAASLP inquiries. It was only in 2009 that Harmon was given that name—and only through contacts she made in successfully appealing denied claims that had been submitted by her private practice.
It is difficult to quantify companies' use of the manual, Harmon said, but providers are using it to appeal denied claims. In addition, several self-insured companies, which are not bound by the state mandate, have agreed to comply with the Autism Equity Act; and some companies have made exceptions to the mandate's limit on number of visits.
TAASLP also compiled a companion manual for consumers. This 356-page guide offers information, guidance, and resources on accessing speech-language and hearing services and includes information about the Autism Equity Act. Many private-practice audiologists and SLPs keep copies in their waiting areas for patients to peruse. Members of the TAASLP Reimbursement Committee also will accompany families to meetings with employers to discuss additional coverage for speech-language and hearing issues. Both manuals may be freely downloaded from the TAASLP website.
Harmon advises other states to compile similar resources. "It's important to give comprehensive, accurate information to the people who will review claims," she said, "and to customize that information based on the laws in a particular state."