Speech-language pathologists and audiologists in schools may face a number of documentation and other questions when providing services to students eligible for Medicaid. Schools have provided Medicaid-reimbursed services since 1988, when Medicaid began paying for medically necessary services provided to children under the Individuals With Disabilities Education Act.
Medicaid regulations vary from state to state because each state administers and partly funds its Medicaid program; as a result, specific Medicaid requirements have proven challenging for clinicians and billing office managers. Medicaid has conducted audits in states where billed services were not properly documented (see The ASHA Leader, Aug. 3, 2010).
School-based clinicians may encounter situations similar to those described in the following scenarios.
Q: My school district requires me to provide Medicaid documentation on all students on my caseload, even though they are not all Medicaid-eligible. Can the school district enforce that requirement?
Yes, it can. Completing the additional paperwork may seem unnecessary, so understanding why schools may require this information may be helpful. First, requirements for Medicaid include demonstration of financial need; therefore, by providing information on all your students, you help protect information about the financial status of individual students and prevent any potential for differential treatment associated with financial need.
Second, because the financial requirements for Medicaid eligibility may change, some students may become eligible—or lose eligibility—for Medicaid during the year. By capturing financial information on all students, the billing office will have the required documentation if circumstances change.
Q: Because information is captured for all students, should I be concerned that information may be used to bill Medicaid for services provided to non-Medicaid students—and that it might appear I am billing fraudulently?
No, you cannot be held responsible. You are providing documentation for all of your students, and it is the responsibility of billing staffers to process bills only for those students eligible to receive Medicaid.
Q: Does Medicaid cover speech-language services for all children who are financially eligible?
No, finances are not the only requirement. Depending on the specific state, only those services deemed medically necessary can be reimbursed through Medicaid, and providers
may need documentation to support that need. Each state develops its own criteria for medical—as opposed to educational—necessity. ASHA's medical necessity document will assist speech-language pathologists and audiologists in demonstrating the distinction between medical need and educational need. The fact that a student has an Individualized Education Program does not automatically determine that the service is educational rather than medical.
Q: Can services qualify for Medicaid if they are provided by a speech-language pathology assistant or an SLP who does not have certification?
The answer depends on the laws of each individual state. Many states allow only services provided by a certified SLP to be billed to Medicaid. Some states will allow services provided under the direction of a qualified provider. Medicaid requires a qualified SLP or audiologist to direct the services and supervise each beneficiary's care. The nature and definition of that supervision are determined by each of the states (see The ASHA Leader, April 5, 2011).
Q: What if I am asked to sign Medicaid billing documentation for students I did not treat and/or for personnel I did not supervise?
Medicaid audits by the Office of the Inspector General have found that some schools fail to use qualified providers to deliver speech-language services. As a result, school administrators may ask their qualified SLPs to sign off on documentation as a workaround to this finding. That request is not reasonable, because the SLP signing the documentation is attesting to his or her knowledge of the student either directly or through careful supervision.
ASHA's Code of Ethics provides guidance on this issue, as noted in the ethics FAQs for schools. SLPs must be firm yet cautious when dealing with administrators who direct them to "sign off" for services they did not provide, such as supervision of other service providers. Clinicians can share with administrators the consequences of violating Medicaid rules and regulations:
- A school district could be required to repay Medicaid funds.
- SLPs and school districts could be prosecuted for fraudulent billing, a criminal activity punishable by law.
For more information on signing off on services not rendered, visit ASHA's online documents. The ASHA Board of Ethics also provides guidance to SLPs and audiologists concerning representations made to obtain insurance reimbursement.
Contact Laurie Alban Havens, MA, CCC-SLP, director of private health plans and Medicaid advocacy (firstname.lastname@example.org), for assistance on Medicaid issues. Contact Heather Bupp, Esq., director of ethics (email@example.com), with questions about ethical concerns.