Several new initiatives on the health care reform horizon may make it easier for private-practice speech-language pathologists and audiologists to receive reimbursement for services from third-party payers.
Most SLPs and audiologists in private practice bill their services directly to the client or to the client's health insurance company or other third-party payer. These payers have different payment arrangements, depending on whether or not the provider has a contractual arrangement with the payer. In the past—and in some places, the present—some insurers paid for speech-language pathology and audiology services only when the services were provided in certain settings (e.g., hospital, rehabilitation clinic), and denied services billed by private-practice SLPs or audiologists.
For the most part, however, private-practice SLPs and audiologists can be reimbursed for services as long as all other requirements, such as medical necessity, are met, although some third-party payers may pay different rates for services provided in different settings.
ASHA and state speech-language-hearing associations continue to advocate for equitable coverage of private-practitioner services. Just as the Patient Protection and Affordable Care Act (ACA) states that benefit design must not discriminate against individuals because of their age or disability, ASHA advocates for the ability of qualified providers, in a variety of settings, to provide medically necessary services. These efforts are beginning to realize success: Blue Cross Blue Shield of Michigan, for example, now allows private-practice SLPs to apply to certain of its networks.
Upcoming changes in health care reimbursement will offer challenges and opportunities for private practitioners interesting in becoming part of new care delivery and payment systems. As a result of ACA, these new systems emphasize quality and efficiency rather than reimbursement for services. Cost control is essential, and providers can share in savings—but only if desired outcomes are achieved.
New initiatives and issues of particular interest for private-practice SLPs and audiologists include:
National Association of Insurance Commissioners (NAIC) working group definitions. Under the ACA, a working group was formed to provide uniform definitions to be used in health care reform measures. ASHA was represented on that working group, and was successful in including "habilitation" as one of the working terms (see January 18, 2011, The ASHA Leader). As a result, habilitation is now being considered for coverage separately from rehabilitation. It is hoped that more insurance plans will include this category in their coverage.
Health Insurance Exchanges. An exchange is an organized marketplace for the purchase of health insurance for the estimated 24 million Americans who do not have employer-sponsored health insurance or who are ineligible for Medicare or Medicaid (see April 26, 2011, The ASHA Leader). The role of SLPs and audiologists in the development of health insurance exchanges vary by state, depending on whether a state allows providers to have input in the selection of plans and coverage options. SLPs and audiologists need to know what plans are being considered for inclusion in the exchanges and what those plans offer. Understanding the selection, benefits, and planned growth of exchanges, and the unique language of the exchange, is the best preparation.
Accountable Care Organizations (ACOs). These new entities integrate local physician group practices with hospitals and other members of the health care system and reward providers for controlling costs and improving quality (i.e., "shared savings"). Shared savings payments would be distributed to ACO participants (physician groups and hospitals) as well as providers/suppliers of services based on negotiation and the ACO's determination "how to equitably distribute shared savings or use the shared savings to meet the goals of the program" (see "Rules Issued for Accountable Care Organizations"). ACOs are likely to contract with a single rehabilitation organization, but they may contract with individual providers. By getting to know the group practices that are forming ACOs, audiologists and SLPs can seek to affiliate with rehabilitation practices or determine other ACO contracting opportunities.
Bundled Payments. This term describes payment to providers per case or episode, rather than for individual services (see August 3, 2010, The ASHA Leader). Bundled payments could be expanded beyond the acute phase of an episode or illness to include the patient's diagnosis. Because payment would be for the diagnosis, it would be based on the outcome of the treatment rather than on a specific number of treatment sessions.
Value-Based Purchasing combines information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays for health. It focuses on managing use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. This concept complements bundled payments to provide reimbursement based on the desired outcome balanced against the cost.
Health Care Provider Nondiscrimination, a section of the ACA, has received little attention. It states, "A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law." ASHA and other organizations representing qualified health care professionals will use this section in advocacy activities if health plans refuse to include private practitioners in their provider networks.