Supervision of Assistants: Billing and Payment Compliance
Supervision requirements of assistants can vary widely by state, setting, and payer. 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 regarding supervision of assistants 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 graduate students, 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 regarding audiology assistants and speech-language pathology assistants vary significantly, so it is very important to review your state’s regulations. When required by state law, assistants must obtain a license or join a state registry prior to engaging in practice. For states without regulations on assistants, this might mean that assistants cannot practice within that state. If your state does not appear to have regulations for assistants, check directly with your state speech and hearing licensing boards. Remember that the state regulations for assistants provide a foundation for practice, but payer policy can vary. Insurance plans can elect to have stricter requirements for assistants or can elect not to cover services provided by assistants. Clinicians may consider establishing supervision and billing policies based on the strictest requirements for payment purposes—whether those requirements are from state law or the payer’s policies—to ensure compliance with all payers.
ASHA Policies and Guidelines
ASHA’s guidelines for certification and supervision of audiology and speech-language pathology assistants are available on the website. It is important to check state laws and regulations before relying on certification requirements to satisfy payment and billing compliance.
Medicare
Currently, federal law does not include audiology assistants or speech-language pathology assistants as qualified providers under Medicare regulations. Therefore, services provided by assistants will not be reimbursable under Medicare until Congress implements a change in the law. Clinicians cannot bill Medicare for services provided by assistants even if state law allows the use of assistants. In addition, Medicare does not allow “incident to” billing of assistant services. In other words, clinicians cannot bill an assistant’s services under the supervisor’s name and national provider identifier (NPI). For more on “incident to” billing, see Medicare Frequently Asked Questions: Audiology and Physician Offices and Groups-Coverage Guidance for SLPs.
Medicaid
Medicaid requirements vary from state to state and among the different programs within a state. The state Medicaid policies are typically different for outpatient, early intervention, and school-based services, so it is important that clinicians verify the requirements for their specific state Medicaid setting by reviewing the program’s website, consulting the provider manual, and/or contacting the provider hotline.
Most state Medicaid programs require the supervising clinician to hold a valid state license and be enrolled provider with the Medicaid program. Some programs require assistants to obtain state licensure or other credentials, and some also require the assistant to enroll directly with the program. Not all states or Medicaid programs within a state allow the billing of services provided by assistants.
Each state Medicaid program that covers and pays for services provided by assistants has different requirements for service delivery and documentation. Some programs may limit the types of interventions that assistants can provide. Programs typically require a certain level of direct supervision or involvement by the supervising clinician in the client’s care. This does vary, so clinicians must check with the program and review the program’s billing manual for accurate requirements.
It's important to remember that state Medicaid programs have very specific rules for credentialing, enrollment, and billing. The act of billing under another clinician’s credentials is known as “incident to” billing or billing “under the direction of” and is not allowed unless the Medicaid program specifically indicates otherwise. Clinicians must check with the program to determine whether (a) they may bill the assistant’s services under the supervisor’s NPI (“incident to”) or (b) the assistant is required to enroll and bill directly, with the required level of supervision. Some programs might also use a special modifier or other code to indicate when an assistant provided a service. Currently, there are no universal modifiers or codes for audiology and speech-language pathology assistants, so it’s important for the clinician to check directly with the Medicaid program and/or the program’s billing manual.
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. In states with licensure for assistants, it is more likely that a commercial insurance plan will reimburse for services by assistants because most payers require providers to be licensed. However, because Medicare does not recognize audiology and speech-language pathology assistants, and commercial insurers often follow Medicare’s lead, coverage within commercial insurance can be challenging. Not all commercial insurance plans reimburse for services provided by assistants. Clinicians must be sure to follow the laws of their state and the policies of the insurance plan being billed.
Insurers who do pay for services provided by assistants often have different rules for billing. In most cases, supervising clinicians will need to be enrolled with the insurance plan and hold valid state licensure. Clinicians must check with the insurance plan to determine whether (a) they may bill the assistant’s services under the supervisor’s NPI (“incident to”) or (b) the assistant is required to enroll and bill directly, with the required level of supervision. Clinicians should never bill an assistant’s services under their own credentials and NPI unless the insurance plan explicitly allows it. To maintain compliance, it is important to bill services provided by assistants in the manner outlined by the insurance plan. Because policies are so variable, it is important to check with the patient’s plan directly.
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.
