Medicaid Guidance for School-Based Speech-Language Pathology Services: Addressing the “Under the Direction of” Rule

Preamble

This document presumes that services provided to students who are eligible for Medicaid and receiving speech-language services in schools will be provided in a “safe and efficient manner in accordance with accepted standards of practice” (Medicaid; U.S. Department of Health and Human Services [DHHS], 2004) and in accordance with Principle I of the ASHA Code of Ethics, which states that “individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally” ( ASHA, 2003).

Associated documents: Position statement, technical report, guidelines

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Assumptions

This document details the knowledge and skills needed by speech-language pathologists who are involved in billing Medicaid for speech-language pathology services provided in public schools to children eligible for special education. It is founded on several assumptions.

The first assumption is that speech-language pathologists have general background knowledge and skills in evidence-based clinical practice and meet their obligation to pursue continuing education to maintain those skills. The second assumption is that any speech-language pathologist serving as a supervisor for another person who is providing services “under the direction of” a qualified speech-language pathologist has an interest in serving as a supervisor. Thirdly, any supervising speech-language pathologist is assumed to have knowledge and skills about the clinical process and about evidence-based practice for providing supervision. Lastly, it is assumed that speech-language pathologists are current in their knowledge of Medicaid requirements and of evidence-based practice in clinical and supervisory practice.

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Knowledge and Skills Regarding Medicaid

Speech-language pathologists need a thorough understanding of the Medicaid policies and procedures regarding the special education billing program and the interface between these and education requirements. Clinicians seeking to gather this information will often find information from their state's Medicaid and education agency Web sites and via training for service providers that is offered by Medicaid. The specialized knowledge base is as follows:

Knowledge required

1. Legal authorization for providing and billing for services to Medicaid-eligible students in public schools

2. Overlap between the concepts of “medical necessity” and “educationally relevant”

3. Federal qualifications of speech-language pathologists, as required by Medicaid and the Individuals with Disabilities Education Act (IDEA)

4. State qualifications of speech-language pathologists, as required by Medicaid and the state education agency

5. Federal and state documentation requirements for “sign-off” on services provided by someone not meeting the federal qualification requirements

6. Federal and state documentation requirements for physicians' signatures

7. Speech-language pathology service delivery models that are reimbursable by the state's Medicaid agency

8. Codes (CPT/ICD-9) required by the state's Medicaid agency

9. Federal and state documentation requirements for documentation of services provided

Skills required

1. Navigate the state agency policies and procedures to determine those that apply to the special education billing system.

2. Educate district administrators and speech-language pathologists on Medicaid requirements and procedures.

3. Advocate for establishing or changing state Medicaid policies, procedures, and forms.

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Knowledge and Skills Regarding Supervision [1]

The focus of supervision for Medicaid reimbursement is to ethically apply the supervisory process, to ensure Medicaid-eligible students are “receiving services in a safe and efficient manner in accordance with accepted standards of practice” ( U.S. DHHS, 2004), and to determine and implement levels of supervision appropriate for each supervisee. Supervisors will find the following resources helpful:

• ASHA Position Statement on Supervision (1985)

• ASHA Knowledge and Skills for Supervisors of Speech-Language Pathology Assistants (2002)

• ASHA Guidelines for the Training, Use, and Supervision of Speech-Language Pathology Assistants (2004)

Although the ASHA document, Knowledge and Skills for Supervisors of Speech-Language Pathology Assistants ( 2002), is specific to supervising speech-language pathology assistants, much of what it covers (e.g., building effective working relationships, planning and executing supervisory conferences, and maintaining clinical records) is germane to working with supervisees at any level. This section describes additional knowledge and skills needed for effectively supervising those providing services for Medicaid reimbursement in the schools.

Supervisors have the knowledge and skills to:

1. Determine the appropriateness of evaluation and individualized education programs (IEPs) for the Medicaid-eligible students they supervise.

   Knowledge required

   1. Understand curriculum-based assessment and intervention techniques.

   2. Understand the school's curriculum and how speech-language intervention can improve a student's learning outcomes.

   3. Understand the range of possible service delivery models (e.g., classroom based, consultation, team teaching, pull-out, group) and determine which model(s) best meets a student's needs.

   Skills required

   1. Assess the IEP to determine if it is appropriate.

   2. Convene the appropriate school-based team to revise the IEP, if modifications are needed.

2. Assure that assessment and intervention services provided to Medicaid-eligible students meet accepted standards of practice given identified concerns.

   Knowledge required

   1. Understand culturally, linguistically, and educationally appropriate assessment and intervention practices for school settings.

   2. Understand the clinical process.

   3. Understand clinician skills needed to effectively implement assessment and intervention plans.

   4. Understand how to objectively assess appropriateness of services provided.

   Skills required

   1. Instruct, demonstrate, and/or consult with the supervisee regarding best practices in assessment and intervention for Medicaid-eligible students.

   2. Utilize objective observation strategies to analyze and assess supervisee skills.

   3. Determine when supervisory contacts must be increased beyond minimum levels to assure that services meet accepted standards of practice.

   4. If supervisee does not provide services consistent with acceptable standards of practice, follow district-developed procedures for targeting improvement of supervisee skills with specified consequences if goals are not achieved (see the companion Guidelines document [ ASHA, 2005]).

3. Provide supervision appropriate to the needs of individual supervisees.

   Knowledge required

   1. Understand the supervisory process, including 13 tasks of supervision and how the process should be applied given individual supervisee level and needs (see the ASHA Position Statement on this topic [ ASHA, 1985])

   2. Understand the continuum model of supervision and appropriate supervisor style for each supervisee stage

   3. Understand credentials and educational and clinical background of each supervisee to determine his or her supervisory needs

   Skills required

   1. Determine supervisee needs given educational/clinical background, Medicaid-eligible students to be served, and other relevant issues.

   2. Utilize appropriate supervisory style to meet supervisee needs, such as modeling, demonstration, direct teaching, collaborative problem-solving, and consulting to affirm student goals and treatment approach.

   3. Assist supervisee in developing self-analysis skills to facilitate personal growth and development of clinical ability.

4. Build and maintain an effective working relationship with supervisees.

   Knowledge required

   1. Understand the components of effective working relationships and variations in learning and communication styles.

   Skills required

   1. Establish a clear understanding of roles and responsibilities.

   2. Utilize clear and effective interpersonal communication.

   3. Validate and build on skills of the supervisee.

   4. Establish and maintain a climate of mutual respect.

5. Effectively use supervisory contacts, including conference calls with supervisee, to review student progress, clinical reports, records, and data, to determine the appropriateness of the supervisee's performance.

   Knowledge required

   1. Understand recommended frequency and focus of indirect supervisory contacts for Medicaid reimbursement in the schools.

   2. Understand indicators of student growth in meeting established objectives.

   3. Understand standards for written reports and records in educational settings.

   4. Understand indicators of supervisee skill in providing effective clinical services.

   Skills required

   1. Together with supervisee, establish agenda for supervisory conference.

   2. Discuss student progress and identify any needed modifications in goals, intervention approach, and/or techniques used.

   3. Review reports and records and recommend revisions as needed.

   4. Provide objective feedback to supervisee about skills, identifying both positive aspects of performance and areas where skills should be improved.

   5. Encourage and facilitate supervisee self-analysis and evaluation.

6. Maintain appropriate records of direct and indirect supervisory contacts.

   Knowledge required

   1. Understand frequency and focus of direct and indirect supervision recommended when supervising Medicaid-eligible students in the schools

   2. Understand documentation requirements

   Skills required

   1. Develop or obtain forms for record-keeping of direct and indirect supervisory contacts for each Medicaid-eligible student.

   2. Document direct and indirect supervisory contacts for each Medicaid-eligible student.

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Knowledge and Skills Regarding Ethical and Legal Issues

School-based speech-language pathologists who agree to assume the role of supervisor for Medicaid reimbursement purposes must possess the knowledge and skills necessary to effectuate the provision of services in both a legal and an ethical manner. Further, the supervising speech-language pathologist needs to understand how and when to communicate information about ethical responsibilities to administrators and/or employers. This section describes the knowledge and skills required to do so competently.

1. Apply the supervisory process consistent with legal mandates.

   Knowledge required

   1. Understand federal and state statutes and their respective rules/regulations as well as agency-specific guidelines that govern supervision of professional services.

   2. Understand federal and state Medicaid agency requirements governing reimbursement and supervision.

   3. Know the state licensure law governing the practice of speech-language pathology and audiology.

   4. Where applicable, know the state education agency's guidelines regarding supervision of services.

   Skills required

   1. Distinguish how the laws and regulations dovetail in their requirements and how they differ in stringency.

   2. Determine supervision that would comply with, and satisfy, Medicaid's requirement that supervised services are provided to Medicaid-eligible students “in a safe and efficient manner in accordance with accepted standards of practice” ( U.S. DHHS, 2004).

2. Apply the supervisory process consistent with ethical practices.

   Knowledge required

   1. Understand the ASHA Code of Ethics as well as the professional obligation to “never transfer ethical responsibilities to employers, administrators, or supervisors to whom we report” ( Shinn, 2004).

   Skills required

   1. Maintain ethical conduct and decision making that holds paramount the welfare of the students served as required by Principle I of the ASHA Code of Ethics ( ASHA, 2003) and its guiding Rules of Ethics.

   2. Instruct supervisees of ethical prescriptions and proscriptions pursuant to the Code of Ethics.

   3. Communicate professional ethics to administrators and/or employers prior to the assumption of the supervisory role to preclude potential conflicts.

   4. Discuss the roles and responsibilities of both supervisors and supervisees for Medicaid reimbursement purposes with administrators and/or employers prior to the assumption of the supervisory role.

   5. Communicate ethical responsibilities to administrators and/or employers at onset of perceived conflict.

   6. Resolve ethical dilemmas through advocacy of the Medicaid requirement to ensure that services are provided in a “safe and efficient manner in accordance with accepted standards of practice” in concert with the accepted ethical standards of practice mandated by the profession's Code of Ethics.

   7. Resolve ethical dilemmas by advocating for the prevention of financial liability on the part of the school district where services provided do not comply with, nor satisfy, the Medicaid rule that mandates quality services in accordance with accepted standards of practice.

   8. Read and know the terms of the Professional Negotiations Agreement (i.e., the union contract).

   9. Consult union representatives for support and assistance in persuading school district administration to comply with legal and ethical professional mandates.

   10. Consult with ASHA National Office staff for support and assistance in ensuring compliance with legal and ethical professional mandates.

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Knowledge and Skills Regarding Workload Management

Medicaid supervisors have the knowledge and skills to establish a workload that incorporates sufficient time to engage in the full range of roles and responsibilities needed to ethically meet the needs of Medicaid-eligible students and to maintain compliance with federal and state Medicaid requirements.

Knowledge required

1. Understand the ASHA workload analysis approach to establishing caseload standards ( ASHA, 2002), including:

   1. Definition of workload analysis

   2. Identification of relevant roles and responsibilities, including direct supervision, indirect supervision (i.e., record review, paperwork, conferencing), interfacing with billing agent or administration, orientation with new supervisees, travel, and training

   3. Determination of the time needed to provide adequate supervision based on factors such as the number of supervisees, number of students, complexity of cases, and the level of supervision needed based on supervisees' skills to ensure services are consistent with accepted standards of practice and are delivered in a safe and efficient manner

Skills required

1. Ability to apply the workload analysis approach by documenting the needed time and resources (e.g., support staff, laptop computers, travel reimbursement) and scheduling activities within the work week

2. Effective communication skills to explain to and negotiate with administrators regarding the time and resources needed to engage in Medicaid supervision activities

Notes