Payment Policy Guidance for Speech-Language Pathology Clinical Fellows

When States Do Not Offer Licensure

ASHA’s clinical training standards for speech-language pathologists (SLPs) are robust and include an extensive clinical fellowship (CF) under the supervision of an ASHA-certified SLP (full details on ASHA’s CF requirements for both Clinical Fellows and their mentors can be found on the ASHA website). The CF is often also a requirement for state licensure. However, many payers—such as state Medicaid agencies, Medicare, and private insurers—can establish personnel qualifications for reimbursement that do not recognize Clinical Fellows as qualified clinicians for the purposes of reimbursement. This is often because a state does not offer licensure to Clinical Fellows—as in the case of several states, including the District of Columbia, Connecticut, Hawaii, Massachusetts, and Tennessee. The following information is designed to help Clinical Fellows, their mentors, and employers understand the conditions of payment for services provided by Clinical Fellows in states that do not offer licensure.

Key Considerations

• The ability to be reimbursed for the services of unlicensed Clinical Fellows varies by payer. 
• Many payers require licensure for reimbursement.
• Statutory provisions supersede regulatory and subregulatory guidance.
• Supervision requirements are commonly higher for unlicensed Clinical Fellows, and specific requirements vary by payer. ASHA’s mentorship requirements for the CF may not align with payer requirements.
• Submitting claims for services performed by an unlicensed Clinical Fellow through a facility or the supervising SLP may not be possible.
• The perception of Clinical Fellows varies on the basis of ASHA standards, payer policy, and state law.

See also:  Reimbursement Scenarios for Clinical Fellows

The ability to be reimbursed for the services of unlicensed Clinical Fellows varies by payer.

Unlicensed Clinical Fellows, their mentors, and their employers should check with each payer directly to determine the personnel qualifications for reimbursement. If licensure is required, then you should also clarify under what circumstances the unlicensed Clinical Fellow’s services might be reimbursable. Guidance on Medicare reimbursement for unlicensed Clinical Fellows can be found on ASHA’s website.

Many payers require licensure for reimbursement.

Medicare

According to Section 1861 of the Social Security Act (the federal law that dictates coverage guidelines for the Medicare program), a qualified speech-language pathologist is defined as follows:

The term "qualified speech-language pathologist" means an individual with a master's or doctoral degree in speech-language pathology who—

1. is licensed as a speech-language pathologist by the State in which the individual furnishes such services, or,
2. in the case of an individual who furnishes services in a State which does not license speech-language pathologists, has successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience), performed not less than 9 months of supervised full-time speech-language pathology services after obtaining a master’s or doctoral degree in speech-language pathology or a related field, and successfully completed a national examination in speech-language pathology approved by the Secretary.

At this time, 49 states offer licensure to SLPs; therefore, section (ii) of the Act does not afford protection to Clinical Fellows in states that license SLPs but do not license Clinical Fellows. If a state eliminated licensure completely for all SLPs, then Clinical Fellows could potentially provide reimbursable services to Medicare beneficiaries under the protection of section (ii); however, most Clinical Fellows would probably not meet the requirement for 9 months of supervised full-time speech-language pathology services after obtaining their degrees.

Most Medicare regulations, such as those outlined in policy manuals and in the conditions of participation for facility settings, also require licensure.

Medicaid and Private Insurers

National, or even regional, standards for Medicaid and private insurers are not available. When contracting with a private payer or state Medicaid agency, it is important to talk to the payer directly to determine the personnel qualifications. If a payer requires licensure for reimbursement and your state does not license clinical fellows, you should clarify the requirements (such as supervision level) that will allow the Clinical Fellow’s services to be reimbursed.

See also: ASHA’s Medicaid Toolkit: Qualified Providers

Statutory provisions supersede regulatory and subregulatory guidance.

It is important to understand that regulations issued by the Medicare program are intended to interpret federal law. Although some Medicare regulations appear to allow for reimbursement for services provided by unlicensed Clinical Fellows, a case could be made by the federal government that the Social Security Act is clear and that licensure is required. Conversely, upon audit, a provider could argue they were following Medicare regulations and could successfully challenge audit findings. In the end, ASHA members need to take into consideration the Association’s guidance—which is designed to help them comply with the law and avoid negative audit findings—and their own risk assessment to determine how to proceed.

One example of a discrepancy between the Social Security Act and federal Medicare regulations can be found in Appendix PP of the State Operations Manual for skilled nursing facilities (SNFs). These regulations state that a qualified SLP is one who is licensed, certified, or regulated in their state. Currently, Alabama and Tennessee regulate Clinical Fellows but do not offer licensure. It could be interpreted that, in SNFs located in these two states, Clinical Fellow services could be reimbursed under Medicare. But in all other regulatory guidance for other practice settings reviewed by ASHA—including hospitals, home health agencies, and outpatient settings—personnel qualifications reiterated the requirement for licensure as outlined in the Social Security Act.

Supervision requirements are commonly higher for unlicensed Clinical Fellows, and specific requirements vary by payer. ASHA’s mentorship requirements for the CF may not align with payer requirements.

Many people believe that by co-signing a Clinical Fellow’s notes, they have met a payer’s supervision requirements. ASHA has established a detailed process associated with the mentorship of Clinical Fellows, for payers such as Medicare that clearly require licensure for reimbursement, ASHA’s professional mentorship guidelines cannot serve as a substitute. Many payers view supervision as both (a) participation in documentation and (b) a physical presence and involvement in the patient’s treatment. Again, private payers and state Medicaid agencies vary in how they define supervision, so you should check with these payers directly to determine how to proceed.

Under Medicare, supervision requirements vary by practice setting. We recommend that you review Medicare’s guidance in detail, but, in summary, for Part B settings (e.g., outpatient settings such as private practices), direct supervision is required—meaning that the licensed SLP must be physically present in the room, directing the services of the unlicensed Clinical Fellow. In most Part A (inpatient) settings, general supervision is required—meaning that the licensed SLP must be somewhere in the facility and available, if needed. However, unlicensed Clinical Fellows and their mentors working in SNFs should be aware that the guidelines for Part A SNF patients were refined in 2011, leading to concerns that the supervision requirements might be slightly stricter in this particular Part A setting.

Submitting claims for services performed by an unlicensed Clinical Fellow through a facility or the supervising SLP may not be possible.

Can the services of an unlicensed Clinical Fellow be billed through the billing number (e.g. National Provider Identifier [NPI]) of the facility or supervising licensed SLP? The answer to that question depends on the practice setting and the payer. Under Medicare in outpatient settings, Medicare expects the NPI of the rendering provider to be listed on the claim. If the supervising licensed SLP did not provide the appropriate supervision level, then the services should not be billed under the supervising licensed SLP’s NPI. In facility settings such as SNFs, the services are technically billed under the facility’s—not the individual clinician’s—NPI. Despite this, because the Social Security Act requires the SLP to be licensed, if the SNF billed Medicare for the services of the unlicensed Clinical Fellow without the appropriate level of supervision by the licensed supervising SLP and this was discovered through an audit or other means, the SNF could be forced to repay the Medicare program for those services.

The perception of Clinical Fellows varies on the basis of ASHA standards, payer policy, and state law.

ASHA firmly believes that Clinical Fellows are qualified providers, subject to ASHA’s mentorship standards, who have graduated from accredited master’s programs and who should not be considered students. Many states, even those who have not offered licensure to Clinical Fellows, also have a process for recognizing Clinical Fellows and allow them to practice under state law. But payers who require licensure for reimbursement purposes may classify unlicensed Clinical Fellows as students or other practitioners of “lower” status than an SLP. Under Medicare, for example, the concept of the Clinical Fellow is not recognized in any way in law or regulation. Additionally, speech-language pathology assistants are not currently recognized as qualified personnel under Medicare in the same way as physical therapy assistants or occupational therapy assistants. Without other categories by which to classify them, it appears that Medicare would view unlicensed Clinical Fellows as students for the purposes of supervision requirements and reimbursement. This would restrict, but still allow, Clinical Fellows to be engaged in clinical treatment of Medicare beneficiaries—but only when under the appropriate level of supervision by a licensed SLP.

Reimbursement Scenarios for Clinical Fellows

An SLP Clinical Fellow is hired in a skilled nursing facility (SNF) in Oklahoma. The Clinical Fellow’s employer wants her to provide and bill for services to Medicare beneficiaries. Is this allowable?

Yes—as long as she has obtained a provisional/temporary license in Oklahoma. Licensed Clinical Fellows are considered fully qualified to provide services according to Medicare regulation.

What if the same SLP Clinical Fellow wanted to provide and bill for services to Medicare beneficiaries in a state without provisional licensure?

If she resides in a state without a provisional license for Clinical Fellows, she would not be able to bill Medicare directly for her services. Although ASHA views a Clinical Fellow as an independent provider requiring mentoring from a seasoned SLP who holds current ASHA certification and/or state licensure, many payers—including Medicare—would not reimburse the facility for her services as long as she does not hold a license. In this case, because she is not an independent practitioner under Medicare rule, her employer would need to provide direct supervision. 

A recent graduate of a speech-language pathology master’s degree program in Missouri is granted a full license upon completion of all coursework, practicum, and passage of the Praxis exam. There is no provisional/temporary licensure requirement in Missouri. Can this Clinical Fellow work in a hospital and bill insurance?

If the payer requires only a license, then the answer is yes. If the payer requires the CCC or equivalent, then the licensed new graduate cannot bill independently without completing the Clinical Fellowship first. Despite having a full license, the new SLP may not meet certain payer requirements. In every case, the Clinical Fellow, mentor, and employer needs to check with the payer to see whether licensure is sufficient or whether the CCC or equivalent is required.

Additional Resources

• Questions? Contact reimbursement@asha.org  
• The ASHA Leader: The Clinical Fellow Licensure Conundrum
• The ASHA Leader: Can I? Should I?