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

Working Group on Medicaid Reimbursement

Medicaid guidance for reimbursement of speech-language services ^[1] provided in school settings is specific regarding the qualifications of the speech-language pathologist providing those services, but offers no specific direction regarding reimbursement for services provided by clinicians not meeting those standards. Professionals who do not meet the qualification standards may provide services “under the direction of” a qualified speech-language pathologist. In the absence of specific federal guidance on the requirements for “under the direction of” services, states develop their own criteria, resulting in great differences nationwide in the qualifications of personnel who are providing services for Medicaid billing in the schools and creating the potential for several untenable legal, ethical, and workload situations for speech-language pathologists.

It is the position of the American Speech-Language-Hearing Association that in order to assure provision of quality services to students with speech-language impairments, certain minimum qualification standards must be met for both the qualified speech-language pathologist (the supervisor) and the lesser or unqualified clinician (supervisee). The recommended minimum qualifications for supervisors are an ASHA Certificate of Clinical Competence (CCC) and a contractual relationship with the employer of the supervised clinician. In addition, it is preferable for the supervisor to have an active interest and training in supervision, two or more years of experience after receiving the CCC, and a willingness to serve in this role.

ASHA recommends that, at a minimum, supervisees (1) hold a standard state education license or certificate in speech-language disorders, (2) be a graduate student intern participating in an ASHA accredited graduate program and receiving supervision in accordance with the supervision requirements of the Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA), (3) be an undergraduate intern participating in an undergraduate program in communication disorders and receiving supervision equivalent to the supervision requirements of the CAA, or (4) be a speech-language pathology assistant supervised according to ASHA guidelines. This standard excludes persons with emergency credentials from a state department of education and paraprofessionals other than speech-language pathology assistants.

The nature, frequency, and length of supervision must be adequate to assure that quality speech-language services are provided. The following levels of observation, contact, and review are considered appropriate to accomplish this goal, with the understanding that the time allocation will vary based on the individual circumstances and the needs of the student and supervisee:

• At the beginning of each school year, the Individualized Education Plan (IEP) for each Medicaid-elibible student will be reviewed to determine that the speech-language service plan is appropriate;

• At least twice per quarter, each Medicaid-eligible student receiving speech-language services will be directly observed;

• At least twice per quarter, the supervisor will confer with the supervisee about each Medicaid-eligible student;

• At least twice per quarter, relevant paperwork for each Medicaid-eligible student will be reviewed to determine that the services provided are consistent with those prescribed in the IEP.

In order to assure that the supervising speech-language pathologist provides appropriate direction to the supervisee, sufficient time shall be allocated within both the supervisor's and the supervisee's workload to address the requirements for both direct and indirect supervision. The time allocation necessary will vary based on the individual circumstances. In addition, it is critical that the supervisory contacts be documented.

A speech-language pathologist must keep in mind that participation in the Medicaid reimbursement program places him/her in a fiduciary position; that is, the speech-language pathologist is entrusted by the government to provide quality services and/or supervision of services and to bill appropriately for those services in accordance with Medicaid regulations. Further, the speech-language pathologist must comply with that state's Medicaid plan as well as with the state licensure laws, state education agency credentials, and professional policy documents, including the ASHA Code of Ethics. The practitioner should be fully informed of the various federal, state, and local regulations affecting his/her professional practice as well as the ethical proscriptions involved. When there may be a potential conflict in requirements and ethical standards, the speech-language pathologist should adhere to the highest standard.

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