Speech-language pathologists—and the school systems that employ them—often are confused and frustrated by the complex process of receiving Medicaid reimbursement for their services.
And who can blame them? Medicaid is jointly funded by state and federal governments, and although the federal government establishes implementation guidelines, each state develops its own administrative plan. In reality, then, Medicaid is 50 separate programs, each with its own rules for the type, amount, duration and scope of services it will cover—and who may provide them (see "Medicaid and Supervision in Schools," April 5, 2011).
For instance, a state Medicaid program may reimburse for medically necessary treatment provided by a licensed speech-language pathologist—but the program might, depending on the state's Medicaid law, also allow services to be provided by an unlicensed SLP, a paraprofessional, a speech-language pathology assistant or another staff person providing services under the direction of a licensed SLP.
Requirements become even cloudier as each state also determines its own guidelines for "under the direction of"—that is, the supervision of unlicensed providers who are delivering services—to verify that the needed services have been provided. There is little federal guidance on this issue. In 1992, the Centers for Medicare and Medicaid Services indicated that "direction" means a qualified provider must:
- See a patient/client at least once.
- Prescribe the type and frequency of treatment needed.
- Periodically review the need for continued services.
- Accept responsibility for all services provided by the individual he/she is supervising.
SLPs should check with their state's Medicaid office to obtain the rules for supervision of school personnel (other than licensed SLPs) providing services to Medicaid-eligible students if the school is seeking Medicaid reimbursement.
In some school districts, however, SLPs report being asked to sign off on Medicaid billing documents for services provided by others. Before signing or billing for these services, you should consider that your signature means you have adequate knowledge of the client, supervisee and nature of the service provided, as well as documentation reflecting the skilled service provided.
Can schools bill Medicaid for services provided by clinical fellows?
As with most Medicaid-related questions, the answer depends on the state. Here are three examples of how states interpret this issue:
- Some states issue temporary or interim licensure to CFs that allows the CFs to bill Medicaid for services provided in schools.
- Some states—even those with temporary licensure—restrict the scope of practice and the services provided by the CF, and require the CF supervisor to bill for the services. This rule might require the supervisor to provide more frequent supervision than mandated for ASHA certification.
- In states that do not issue a temporary or interim CF license, the CF is usually unable to bill Medicaid independently. Regulations in Utah, for example, state that "Speech-language students in their final clinical fellowship year may provide Medicaid services under direct supervision, but Medicaid billing must be done by a licensed speech-language pathologist."
Does direct supervision mean that the supervisor is with the supervisee 100 percent of the time?
Not usually. Direct supervision means onsite, in-view observation and guidance by an SLP while the unlicensed staff member or speech-language pathology assistant is performing the treatment. The frequency/intensity of the supervision may be related to the needs of the supervisee.
Does direct supervision mean that the supervisor must be onsite all the time?
Each state Medicaid program specifies and defines the amount of supervision required, usually a combination of onsite and offsite.
What are other important considerations for Medicaid supervision and billing?
- If billing is submitted under your signature/license, you must be familiar with the client with full understanding of the services that have been provided.
- If you supervise more than one person, make sure you stay within the state's limits for how many individuals you can supervise, and can maintain your caseload as well.
- The level of supervision may vary according to the level of expertise of the supervisee. However, even for a seasoned supervisee, remember that it is still the supervisor's signature and license submitted for billing.
Where can I find more information and answers to state-specific questions?