Something to think about

In our field, billing for insurance and medicaid is a necessary evil (it seems).

Recently, omedical-billing-claim-denials-resized-600n the ASHA community page someone commented about billing for medicaid. I’ve heard the discussion before, and it was definitely one of the things I’ve asked about in interviews…but there’s two very different sides. I’d love your opinion on each side. 

Side 1: Whether or not someone is on medicaid is too confidential for the SLP. Therefore, an outside entity (usually the billing company) has to do the medicaid filing. Therefore, the SLP must submit billing for each and every student on his/her caseload, submit it to the billing entity, who in turn actually bills medicaid. I’m sure there’s a wonderful little fee associated with such transactions, but no one ever talks about that.

I have a couple of issues with this.

FERPA…and/or HIPAA. According to the US Dept. of Education the only individuals with whom a school record can be shared legally is:

  • School officials with legitimate educational interest;
  • Other schools to which a student is transferring;
  • Specified officials for audit or evaluation purposes;
  • Appropriate parties in connection with financial aid to a student;
  • Organizations conducting certain studies for or on behalf of the school;
  • Accrediting organizations;
  • To comply with a judicial order or lawfully issued subpoena;
  • Appropriate officials in cases of health and safety emergencies; and
  • State and local authorities, within a juvenile justice system, pursuant to specific State law.

Now, I don’t know about you, but I can’t find Medicaid billing entity on that list anywhere. It’s certainly not in the “appropriate parties in connection with financial aid to a student” because every student is entitled to a Free and Appropriate Public Education and doesn’t pay for school services (that is more for colleges/universities). Medicaid billing certainly isn’t a study (although, I suppose it could be one…. how many hours of useless Medicaid billing does it take before the SLP throws her hands up in disgusts and quits?).

The second issue is Workload. Many SLPs, have upwards to  80 – 100 students on their caseload. Of those, let’s say as many as 50% are Medicaid eligible. That’s a huge inflation. Unless it’s an inner city extremely poor school district, it won’t be that many (particularly since the entity has to receive permission from the parents to bill, have Medicaid numbers, and doctors prescriptions saying it’s necessary and we know how that flow of information typically goes).

Now to bill for Medicaid, each district is different. (Honestly, I’m not sure if it’s a district thing, or a state thing. Once again, here in my district we are doing things RIGHT as it is easy and not time-consuming!)  Typically at the very least, you have to document the date, number of students who attended (individual, group) and length of session. Some districts require SOAP notes to include growth, percentages, activities, etc. So actual time spent billing could be as small as 2 minutes per kid to as long as 5-10 min per kid (per week). Oh, and don’t forget that if there’s an SLPA or another SLP who isn’t able to sign off on Medicaid, then the SLP that IS able to has to do file reviews and bill for those students as well even though she doesn’t actually SEE those students (talk about having faith! My license on the line in the hopes that someone else is doing what they’re supposed to be doing and not committing fraud???).

So…now let’s figure out Medicaid billing for someone who has to submit billing for every student. Hmmm. 80 x 2 = 160/week, 80 x 5 = 400 minutes/week.

400 minutes = that is 6.6 HOURS of Medicaid billing…at least 50% of it which is NOT NEEDED because the kid is not on Medicaid. What could we do with 3-6 hours of paperwork time each week? (I know…maybe not take work home where we work for countless hours for free?)

So, the SLP (OT/PT too) are supposed to spend an extra 3 hours a week doing paperwork that is useless all because it’s too confidential to know who is on Medicaid? But it’s okay for a Medicaid billing company to get paid for knowing who is receiving school-based speech services (even though it’s a violation of true FERPA)? How does THAT work?

Side 2: The SLP is responsible for getting the Medicaid permission forms filled out and only bills for the students they see who are actually RECEIVING Medicaid (novel idea, right?). The SLP has the same responsibilities, but only bills for those who qualify.

So… let’s say 40 kids (80 on caseload) x 2 = 80 minutes every week spent on billing… Oh, and if we say 40 x 5 = 200 minutes/week billing. This equals to 3.3 hours of billing time (which is still a lot, but at least it’s for a reason since supposedly the schools receive the money).

The most common reason that I’ve heard for billing everyone, is because schools are afraid of being accused of providing more services for students who are Medicaid eligible in order to get more Medicaid money.

This really is an interesting tangle. Are we, by allowing an outside agency to have access to IEP information violating FERPA? Could we be liable for misuse of that information? If, for some reason, there is a Medicaid billing error who is liable? The SLP who signed off on the information or the Medicaid billing company?

We won’t even get into the whole education vs medical conundrum because that would be an entirely different post.

So…let me know. Do you bill for Medicaid? How many minutes/hours per week does it take you to do so? Do you bill for your entire caseload or only those who are Medicaid eligible? There is obviously some rationale I’m missing, what is it? Leave me a note here, I’d love to hear how it works in other areas besides my little utopia.

Until then…Adventure on!


14 thoughts on “Something to think about

  1. In my district we bill for every student we see – regardless of his/her Medicaid status. Ugh! I can’t count the hours I have spent in front of the computer completing this task. However, I often remind myself that the funding the district receives is paying for the salary of a paraprofessional (so they say…) and we love our support staff!

  2. In Maryland, whether or not a kid is on Medicaid is on their IEP. MA# is actually a section of the IEP and the districts I work with have secretaries who handle the MA billing. Provider submits documentation/coding. A really goofy angle is that at least for AuD/PT/OT in the schools in Maryland it is very limited what codes are accepted. I find this very frustrating bc a lot of the codes I use are not MA billable in the schools from what I’ve been told.

  3. In our district, we have every parent sign a consent for Medicaid billing at the student’s IEP meeting. We have an outside company that checks on Medicaid status and provides us with the electronic filing system. We are told by our district who qualifies and then we enter the information on our own time by the end of the year. About 40% of my caseload qualifies. It is time consuming and I usually do it quarterly to twice a year during conferences when I don’t have parents signed up.It is always low on my priority for my ‘to do’ list. Some staff do the entire year in May right before school lets out. I have a caseload of about 40 and if I had to do all 40 students it would take me about 3 days!

  4. Mary,

    You’re (probably) not violating FERPA/HIPAA because the district has a contract with the service provider that makes them a Business Associate. You can learn more here

    Basically, Business Associate Agreements allow a contract to act on behalf of the covered entity (your district). They have to follow all the rules and they have to isolate their various clients’ information. I have worked in this space on the health insurance side & have many friends working in outsourcing non-SLP stuff (remember, I worked for Perot Systems for 15+ years).

    That said, the rest of your argument makes total sense.

  5. We have parents sign and provide medicaid number at the IEP meeting, THEN I have to submit for every child on my caseload regardless of whether they are medicaid recipients or not. I also have to sign off for rehab assistants. It takes hours to consult with every rehab assistant, review their submissions, approve and post my own sessions. This statement accompanies my approval “I certify that activities being billed under rehabilitative assistance for the above student(s) … on the dates specified …, for which I am knowledgeable of the service provision, and provide weekly consultation to the aide, are not classroom instruction or academic tutoring, but are therapeutic in nature and are necessary for the maximum reduction of each student’s physical/mental disabilities.” TaIk about stress! hate it!

  6. Mary, Thank you for your blog on this issue. When I see SLPs on our Facebook pages complaining about the amount of paperwork they are doing for Medicaid billing, I don’t comment because I have voiced my opinions about this topic before, and every SLP has to make their own decision…but I really appreciate you bringing this subject up and I want SLPs to really consider WHY they are participating in this.

    If you are going to participate in billing Medicaid, educate yourself, and know your personal liability for fraud -ask questions! It is your license and NPI number they are using to bill Medicaid.

    I object to Medicaid Billing, and refuse to participate, for a number of reasons:
    1) The outside agency hired (and paid) to do the billing was not able to provide the required physician’s referrals. When asked, initially, they claimed there was a physician-signed form which covered all students. What? NO! A written physician’s referral Is required for each student, indicating medical necessity. The billing agency then expected SLPs to contact students’ doctors to get these forms completed.
    2) When I realized a family’s personal insurance had to be billed and denied before Medicaid could be billed, and parents were receiving EOBs for this, I see this as a huge conflict for school-based services that are supposed to be “free”! FAPE = Free and Appropriate Public Education. Not to mention, if parents wanted to use their Medicaid for additional private therapy services, the funds were already used by the school.
    3) Due to confidentiality, and the possibility of Medicaid status changing during the school year, we are not told which students are eligible for Medicaid, so billing is required for every student, every month- a huge waste of time.

    Fortunately, when I addressed these concerns with my administrators, they agreed with me! They saw that the billing agency did not understand what was involved, putting our schools at huge risk for fraud; and the money paid to the agency was very costly compared to the return from billing that we received.
    It is important for you, as a school-based clinician, to know and understand what is being required in your state, especially if your district is asking you to co-sign for other SLPs’ services. Ask how much the outside agency gets paid to do this billing? Ask how much money this brings in to the school? Ask where those funds are used – does any of it come back to the SLP Department? You should know the answers to these questions because it is your credentials they are using to bill Medicaid.

    (Stepping off my soapbox now)

    • Great comment Maryann, thank you.

      Several years ago, I had a parent refuse to give me permission to bill medicaid because she believed that it would work against the “cap” and his outside services would be limited. So, I reached out to our ND medicaid office to see if that was the case. What I was told was that for medicaid in the schools, there is no cap – and it does not count against any services they could receive outside of school. I know many SLPs believe that they can’t be on the same day or work on the same goals – but I was told simply that it came out of an entirely different “budget.” That said, it could be every state is different. We, as SLPs who are ultimately responsible, need to find the information as it fits for our state and go from there.

      I completely agree with you regarding making sure that all of the paperwork is in order and following through with all of that work. It is OUR careers on the line – not that of the billing agency, or our directors, or our administrators. OURS.

      Great questions at the end too. I know in a previous school I worked in, the SLP (OT/PT as well) were given a percentage of what medicaid paid to use for supplies, etc. for the classroom. I don’t know that everyone is given that opportunity though (I’m not currently given a set amount, but I’m usually able to receive what I request in the form of supplies each year).

      I wonder how many SLPs have actually dared to argue against billing and had their rationale heard. Great job on that by the way – nice advocacy!

  7. The district in currently working in requires us to complete Medicaid documentation for all students. It’s a very large district with a varied population. We have some schools that would probably have only a handful of students that are Medicaid eligible and other schools where the majority of the caseload is Medicaid eligible. To keep things “fair” and to keep therapists from avoiding working in the schools with higher Medicaid eligible populations, the district decided that everyone would bill for all students. This is only the second year that the district is billing but since they had such good participation last year, they spent some of the money bringing on additional SLPs to allow everyone to have lower caseloads which has been highly motivating for everyone!

    Great post that got me thinking!

  8. My district contracts with a billing service for the actual billings. If we provide the service with a name, DOB, and SSN they can tell us if that person is Medicaid eligible. Then the SLP is responsible for getting parental consent to bill and a physician’s order for services. When all of that is in place the service has us enter session data into their program for billing. It’s not that awful once you have it set up but the process to set it up takes a while. The state I’m in, GA, requires a new physician’s order with every new IEP. That requirement is fairly new and has certainly added to the time involved. It seems like the state is trying to discourage schools from billing Medicaid, which to be honest, would be fine with me. However, I will say that if an SLP bills Medicaid the system I work in will pay their annual ASHA fees and also state licensure. The rationale being our credentials must be maintained in order to be able to bill.
    Sorry for going on so long!

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