Supervision of Graduate Students: Billing and Payment Compliance
Supervision requirements of graduate students can vary by payer and setting. State laws do not typically address graduate student participation in service deliver. It is important to consider all applicable requirements to ensure that you are billing appropriately. ASHA develops its own supervision standards to meet minimum standards for certification, but the final authority on billing and payment requirements is the patient’s insurance plan (payer), in compliance with state law. The following information provides general considerations across payers. However, requirements can vary even within a single payer—depending on the provider type, insurance plan, and setting—so it’s best to check with the patient’s plan directly.
Additional information on supervision of assistants, clinical fellows, and audiology externs is available at Supervision of Assistants, Graduate Students, and Clinical Fellows: Billing and Payment Compliance.
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State Law Considerations
State laws do not typically address graduate student participation in service delivery, and states do not offer a student license. A few states do offer a credential for audiology externs, but this is not common; it is important to check with the state speech and hearing licensing boards directly. Typically, student services are not directly reimbursable, but some payers may allow services provided by students to be billed by the supervising clinician when the student is supervised according to the payer’s policies. Audiology externs are considered students in most states and do not typically hold licenses during their extern year—although this can vary, so it is important to check with the state licensing board directly. Absent a license or other guidance from the payer, audiology externs should be considered student clinicians.
ASHA Policies and Guidelines
ASHA’s guidelines for supervision of graduate students seeking future certification are available on ASHA’s supervision webpages for audiology and speech-language pathology applicants. Note that ASHA’s certification requirements for student supervision may not meet state or payer requirements. To bill appropriately, clinicians must ensure that they follow both state and individual payer supervision requirements.
Medicare
Medicare will reimburse student services only when they are billed by the licensed and enrolled clinician under Medicare’s required level of supervision. The supervision standard varies based on the practice setting. Remember that students are not licensed clinicians and are unable to enroll with Medicare; so, the services provided by the student are considered services personally provided by the licensed audiologist or SLP. Although students can help develop documentation, such as daily treatment notes, the signature of the supervising clinician must be present on all documentation. Supervisors are liable for all services provided under their supervision.
In outpatient settings such as clinics or private practice, students require 100% personal supervision. By Medicare definition, this means that the supervising clinician must be in the room, directing the service, and cannot be engaged in other activities, such as providing services to another patient. Inpatient settings under Medicare Part A, such as hospitals, require direct supervision—meaning that Medicare requires the supervising clinician should be somewhere in the facility and available if the student requires assistance. Supervision level should be based on student skill, patient needs, and any other applicable policies (e.g., state law, the facility’s policies and procedures, university requirements). In skilled nursing facility (SNF) Part A settings, Medicare has made it clear that supervisors cannot see another patient or supervise a second student at the same time that they are supervising a graduate student. See Medicare Coverage of Students: Audiology and Medicare Coverage of Students and Clinical Fellows: Speech-Language Pathology.
The NPI of the supervising audiologist or SLP will appear on the claim for outpatient services. For services provided in a facility (e.g., hospital, SNF), the facility’s NPI appears on the claim form, however, the supervisor is still personally responsible for the services provided by the student.
Medicaid
Most Medicaid programs require a license to enroll as a qualified provider, so students are unable to enroll and bill for their services. Supervising clinicians must hold a valid state license and be enrolled and credentialed with the Medicaid program. Medicaid requirements vary from state to state and between the different state programs and clinical settings, so it is important to check the requirements for your specific state Medicaid program.
The state Medicaid program may dictate the number of students that the supervising clinician is allowed to supervise at a time and what level of supervision is required. The level of specificity in Medicaid program manuals varies; some may simply indicate the supervision requirements, whereas others may restrict what types of services a student can perform. The supervising clinician is responsible for service delivery, so they must review and sign any documentation, while providing the Medicaid program’s required level of supervision, to attest to the quality of the service billed. Some programs indicate that supervising clinicians cannot bill for another session at the same time as the one that they are supervising. If the program does not require 100% supervision, then clinicians should check with the program before seeing another patient at the same time that they are supervising the graduate student. Absent any supervision guidance from the Medicaid program, clinicians should provide 100% supervision of graduate students.
When billing for services provided by students, the supervising clinician must be listed on the claim as the rendering provider and must provide supervision at the level required by the Medicaid program because students cannot enroll or credential with any state Medicaid program. It’s important for supervisors to follow all applicable Medicaid program requirements for supervision and service delivery. Supervisors can check their state Medicaid’s website, consult the provider manual, and/or contact the provider hotline for more information.
Commercial Insurers
Policies by commercial (private) insurers are highly variable; often, different policies can exist under a single insurer, depending on the patient’s specific insurance plan. For example, an employer-sponsored plan could have very different policies from a Marketplace plan from the same insurer. Remember that students are not licensed to practice, so they cannot enroll with insurers or practice independently. Because the graduate student cannot enroll with the payer, all services are billed under the supervisor’s license and NPI, so supervisors are liable for service delivery.
Unlike Medicare, most commercial insurance plans will not have specific instructions for the use of a graduate student in service delivery. Some insurance plans or state laws may indicate a limit to the number of students a clinician can supervise. Keep in mind that within outpatient settings, clinicians can typically supervise only one student at the time in which they deliver services. Absent any guidance from the insurance plan, clinicians in outpatient settings should consider providing 100% supervision, as advised by Medicare. Even if the state or payer allows you to supervise multiple students at the same time, insurance plans may indicate that the supervisor can bill for only one session at a time. This means that they cannot supervise two graduate students at the same exact time or provide services to another patient while supervising a graduate student. When properly supervised, graduate students can provide any type of intervention they are trained to perform and can write documentation. However, all of this needs to be monitored and signed by the supervising clinician. Inpatient settings have some additional flexibility, but supervising clinicians are still liable for the services provided under their supervision. Because requirements are so variable, supervisors must check directly with the patient’s plan.
Questions?
Please contact ASHA’s health care policy team at reimbursement@asha.org for questions related to supervision requirements to maintain billing and payment compliance.
