Methods of Payment for Therapy

Overview

The first thing that one should know is that the remediation (habilitation/rehabilitation) process for typical Speech and Language challenges can be lengthy. Factors include the following: periods.

• the specific condition diagnosed
• the severity of the condition
• your child’s age
• consistency of treatment
• appropriateness of the treatment plan
• the quality of the therapist
• and your child’s innate ability to respond to treatment
  

Therapy will usually last no less than six months and could go on for three years or more. Typically, we see children for about 2 years, however some children are treated in shorter or longer periods.

We will attempt to provide our perspective concerning therapy considerations and costs. However, we advise you to talk to other professionals from all of the sources mentioned in this section and get their opinions firsthand. Please remember we see this situation through the eyes of a private practice.

Frankly Speaking

The fact is that, no matter where your child will receive treatment, it is going to be major budgetary item for whoever pays the final cost. Whether you pay the bill as a private client, the school system pays it as a budgetary item, your insurance company covers the service, or if payment comes indirectly through some State or Federal agency, all therapy services require payment from some source.

The Private Clinic

Before we get into the specific costs of enrolling your child in a private clinic, perhaps it would be more useful to define what you can expect to receive within this type of setting.

• Typically, private clinics offer one-on-one treatment with a finely focused therapist whose sole function is the delivery of high quality, dedicated speech and language therapy.
• At our clinic we also have dedicated rooms for delivery of services.
• As noted before, we also have access to numerous treatment materials and methods.

Although clinics may differ, other comprehensive services provided at our center include:

• Direct, hands-on assistance to the family in educating you about your child’s issues
• Assistance with managing your child’s challenges in the home, school, and community
• Provision of parent inservices by our staff or other speakers invited to the clinic
• Interactive involvement with other professionals the child may see, such as pediatricians, and other professionals (physical therapists, school teachers, etc.) who may be assisting the child
  

Children's Speech Care Center is a Full Service Clinic.

In order to determine if the clinic you are interviewing offers "comprehensive services" simply ask. Listen to the answer and do not prompt them. If they know what information you are seeking they will tell you. If not, you will get a very general reply.

We provide a printable checklist for your convenience that can assist you with gathering information on clinics and therapists.

As a result of differences in services offered, therapy rates vary from clinic to clinic.

An additional mitigating factor is the geographical area that the clinic services..

A recent in-depth poll (Summer 2001) marked off an area from Pacific Palisades (North) and (South) to Anaheim. The western boundary was the Pacific Ocean and the eastern boundary was about ten miles along this North/South corridor. The following results were obtained:

Inside this area, approximately sixty-one clinics were identified. The clinics ranged from pediatric to adult, or to organizations serving a combination of pediatric/adult population.

Prices ranged considerably from the highest at about $135.00 per clinical hour (50 minutes), although a few were higher, to the lowest being $75.00 per hour for non-profit clinics.

This poll included non-profit clinics, which are not in the private sector. Although they work closely with the state and federal government, they are not a direct part of the direct government assistance programs.

Basic rates

West Los Angeles showed the highest rates in the private sector, which, on the average, were around $115.00 p/hr.

You will find private practice rates in the South Bay to be in a range, on the average, between the low nineties to about one hundred ten dollars per clinical hour. Since the majority of our clients (about 70%) are from the South Bay area, we pay particular attention to this region, and place our rates accordingly. We are competitively priced.

Half hour rates are also available and run slightly more than half of the one-hour rates, since the cost of providing services run disproportionately higher.

Our detailed rate schedule is posted in our lobby, also indicating Speech/Language Group and Social Skills Group rates.

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Payment Methods

We provide three basic methods of payment:

Late Remittance Fees

A late payment fee is charged for each period for which a payment is not remitted after the eighteenth of the month. If remittance is not made by the end of the payment month AND no arrangements have been made with our office, services are temporarily put on hold until the current balance is paid, including the late fee.

Please note that a message is included on each invoice that invites you to call a "24 hour, 7 days a week" number and make delayed payment arrangements with us. We understand that from time to time we all need a little assistance, and we can be very accommodating.

Payment practices vary at each clinic and so you should be vigilant in investigating the procedure and practices for each clinic you consider.

Family Financial Assistance

We also can provide financial assistance in the form of a reduced rate for families in need.

These reduced rates are subject to the following provisions:

How long can you expect your child to be in treatment

We will often repeat on this site that treatment for speech and language disorders is not a short-term issue. Therefore effectiveness is very important. Treatment takes time and CONSISTANCY. You should be prepared to make every possible session with your child. This will facilitate the program’s effectiveness and your child’s steady progress.

This is especially important when your insurance is providing payment as they frequently limit the visits, and they look at consistency and progress to determine continuation.

Other types of financial support

Insurance

You will find that a very high percentage of private clinics do not accept direct insurance payment for services.

This is due to a number of factors, the least of which is that many insurances policies do not cover the rates that clinics and clinicians charge. Additionally many insurance companies will not allow the clinic to collect the balance from the client.

This is further complicated by the long waiting period required for the insurance company to remit payment to a clinic or clinician (usually 90 to 120 days.)

There are many other reasons clinics or clinicians do not interface with insurance companies including the complex rules regarding the appropriateness of therapy, the number of reports required and the difficulty in negotiating the maze of insurance procedures.

At Children's Speech Care Center we do offer comprehensive assistance for the family that wants to take advantage of their insurance.

1. We ask for direct remittance to the clinic under its normal terms,
   
2. However, we will assist the client in collecting reimbursement from their insurance provider directly.
   
3. We do this providing the client with whatever the insurance company requires, e.g. reports, therapy insurance codes, and so forth.

About 40% of our families choose this method.

Limitation of Insurance Coverage

We will cover the details of insurance coverage in this section in detail, but first, we offer an important word of caution.

Unfortunately, it is our observation that more and more insurance companies are severely limiting treatment for speech and language deficits. Some will not cover them at all.

When treatment is covered, a veritable minefield of conditions must be carefully negotiated.

The number one task for parents is to UNDERSTAND their specific policy and what is included or excluded with regard to speech and language treatment.

Insurance policies can be difficult to understand, so if you need assistance, consult your program administrator or insurance broker.

Once you have determined whether your policy covers speech and language therapy, you will need to determine the extent of your coverage. That is how long you will be covered.

Policies vary considerably on this issue, so you must be very care to investigate this completely.

We will cover the specific conditions under which insurance companies will not cover speech and language difficulties in the next section.

PDF file
By Ursula Denley, MA., CFY-SLP
Children's Speech Care Center

Finding a way through the insurance web

It can be overwhelming for parents who find out that their child has a diagnosis of a severe speech and language disorder. But this diagnosis is only the start of the dilemma parents will often have to face. For many, one of the greatest will be trying to comprehend their private insurance benefits and whether or not speech/language treatment is included. The subsequent information is provided to help parents manage this perplexing and trying set of circumstances.

The information provided is not a guarantee for receiving insurance reimbursement or coverage. It should be noted that each individual situation is different, as is each individual’s private insurance coverage; and a knowledgeable decision on how to approach the insurance dilemma should be taken.

Reasons Insurance Companies give for Denying Speech and Language Therapy:

Public Schools Provide Speech/Language Therapy

The responsibility of providing speech services for a school age child is that of the public school system, because the schools provide service for the child's educational needs.

Articulation Delay/Disorder is Not Covered in the Policy

An Articulation Disorder is sometimes used to define a variety of speech disorders, some of which have a direct medical component and could be covered by the insurance policy. These can include dysarthria, cleft plate, etc. Some policies do not recognize or cover Verbal Apraxia or Dyspraxia, a motor speech "articulation" disorder, which is not a standard articulation disorder and has a neurological base. According to the American Speech Language and Hearing Association, they described this lack of coverage as "an insurance policy that provides treatment for broken bones, except for breaks of the arm or legs."

If insurance has denied a claim based on an Articulation Disorder, proper documentation should be given to the insurance company disputing the denial, such as a report/letter from the child’s speech therapist or physician.

Policy Does Not Cover For a Preexisting Condition/Rehabilitation Not Habilitation Services are Provided

Most insurance policies cover speech services or rehabilitation services of adults, who have developed speech/language and lost it, but do not cover for children who are developing language. In order for a child to receive services, they must have developed some language, then lost it, and therapy should bring them back to an age-appropriate level.

According to ASHA, language is not a skill that is limited to vocal expression, nor is speech. Language foundations are developing long before a child is born. They also stated, "requirements of first possessing a language ability then losing it, is not related to the medical needs of infants and young children."

Some states have adopted laws that prohibit discrimination based on a person's age. If an adult can receive speech therapy for verbal dyspraxia, a child with the same disorder must also be provided with this service. The United States federal rehabilitation services provision 42 USC 300 e-1 (1), required that speech, occupation, and physical therapies include "habilitation" services under "rehabilitation services".

If insurance has denied a claim based on this, documentation should be provided as to why it should be covered. It should also state that the child's language impairment occurred at a specified point along their development (e.g. resulting from a medical condition such as head injury, chronic ear infections, etc.) and therefore, speech services are rehabilitative.

There must be a Significant Improvement

Information should be provided that documents the child's progress during treatment. All gains in speech and language should be shown. Insurance companies periodically require progress notes. It may be beneficial that the therapist provide these notes, whether or not it is required from the insurance company. If, in the future, any claim for services is denied, proof is provided that the services benefited the child. The insurance company may also periodically require a more formal assessment/progress report to determine measurable gains. These requirements vary with each insurance company and should be investigated and clarified for the speech therapist.

Speech/Language Therapy is Not a Medical Necessity

Insurance companies define a medical need as "services provided by a physician, speech-language pathologist, etc., that identifies and treats a disorder/illness, using appropriate standards of good medical practice and the most appropriate level of service." A clear definition of medical necessity should be provided by the insurance policy.

Based on the definition, verbal dyspraxia qualifies as a medical necessity. Verbal Dyspraxia is described by ASHA, as “a medical condition consistent with the definition of illness and disease,” and that “it is a disorder of body function.” It should be noted that before calling your insurance, be sure you are informed about the diagnosis of verbal dyspraxia and compare it to their definition of medical need/necessity.

Insurance companies are not qualified to evaluate medical needs, they are not hospital or medical facilities. This is the responsibility of a therapist or physician. Insurance companies can only determine medical necessity based on the information provided to them. If the claim has been denied, it is important to ask what is needed to prove medical necessity. Provide them with the information they do not have. Make sure that all reports, evaluations, etc. have been received and that the claims department understands the diagnosis. It is important that you be assertive as to why therapy is medically necessary. Many times the way reports are worded will determine approval or denial. It is recommended that reports should include treatment criteria, long-/short-term goals, and prognosis, as well as duration of treatment.

Policy Does Not Cover for Developmental Delays

Many times, insurance companies will not pay for speech therapy if speech is “developmentally delayed,” which to them, states that the condition will improve over time with or without treatment. Even though the terms Developmental Verbal Dyspraxia/Apraxia of Speech are common to speech therapy, many times the use of these terms is the entire bases for denial. When insurance companies see the word “developmental” they automatically assume developmental delay, and do not see it as their responsibility to pay for therapy with this diagnosis. When claims are denied, many insurance personnel are not aware that Developmental Verbal Dyspraxia is not the same as a Developmental delay. Terms like oral motor planning disorder or speech motor disorder should be used instead.

When diagnostic codes are used by the physician or therapist, a code for developmental delay (315.31) or developmental speech/language delay (315.9) may often be denied. Codes that should be used are (382.9) or (784.5) if they apply. It is important to ask what code the physician or therapist is using. If a claim has been denied due to the fact that the term developmental was used, documentation to the contrary must be provided.

Important Suggestions to follow

Treatment Length
Some insurance policies only cover speech therapy as a short-term benefit. If this is the case, the therapist may need to provide the insurance company with a progress summary every two months, which includes long-term goals, short-term goals, prognosis, and long-term objectives. Toward the end of the two month period, a progress summary must be submitted and detail what goals have been met, and whether or not therapy needs to continue.

Appeal for Services
When a claim is denied, it is important to ask for the denial in writing, and to appeal the decision using the proper procedures outlined by the insurance company. Always document your phone calls made to the insurance company, and get the first and last name of the person to whom you spoke with, as well as the date. Keep good notes about the conversation. Even if the appeal procedures with your insurance company are not successful, sometimes an appeal can be made to the state's insurance commission.

Insurance Agreements
It is important to always review the language of the policy. Break it down so that you understand what each term means and how the insurance company will interpret it. The fact that a policy states that it does not cover for a specific diagnosis is not always so. Look for loopholes in the agreement that might be able to benefit you.

Some helpful Web Sites:
http://www.apraxia-kids.org/links/linkslegal.html
http://www.apraxia-kids.org/topics/insurance.html
http://www.nichcy.org/index.html
http://www.harp.org/
http://www.insuranceattorney.com/claim.htm

NPA and the Public School System

The school system, as a result of the Lanterman Act, is by far the source of most speech and language therapy. We will later explain the process of getting into the system

There are many good speech and language programs in the school system.

You should educate yourself on the procedures regarding special education and IEPs. To get your child special programs or services in the schools requires knowledge of the system and procedures specific to your district.

As with any program, it will work best if you visit with your child’s therapist and stay connected with the therapy process. The parent should take the responsibility to ask questions and seek education and advice on their child’s condition. Parents should know if their child is receiving group and/or individual therapy, and follow up on how the particular service delivery model is working. Parents need to take the responsibility to follow up with the IEP goals and discuss with their clinician how goals are being met, and ways they can facilitate the therapy process. As with any setting, they should also discuss methods being taken for therapy and generalization. Further, if your child is receiving private therapy, therapists in both settings should collaborate.

The school system generally offers therapy during the school year. If your child is enrolled in summer school, they will also receive therapy for that period of time. This is called the extended school year. Generally, therapy is not offered in the month of August.

Given the size of caseloads and demands on therapists’ time, the school system makes an excellent effort in treating the large population of children they serve.

Private Schools

We are not aware of any private (Non-Special Education) schools with on staff speech-language pathologists. But this does not mean they don't exist. You should investigate this option if your children attend a private school.

It is important to know that if your child does attend a private school without a speech-language pathologist on staff to provide services, the state is not obligated to provide the same level of service to your child. You should contact your school to determine the exact nature of the service delivery policy regarding children in private placement. IEP and Evaluation (state paid) services are generally provided, as well as a certain level of staff education, but actual direct treatment may be excluded.

Non Public School Agencies (NPA) and the School System

Payment via NPA

We have provided a link to the Department of Education Internet Site (Link) including detailed information regarding "Non-Public-School Agencies" (NPA) for your review of specific details.

In general, and with regard to payment, an NPA is a state certified private clinic agency that is entrusted with providing (in our case) speech and language services for children in the "public school" sector who cannot be served within the means of the school they attend.

Your child must qualify for this service, and must complete the IEP process (link) first. This is a lengthy process, but its successful navigation can lead to full payment of your child speech and language therapy at our clinic, or any NPA clinic, as is appropriate.

Make sure to specify that the NPA clinic or clinician you select is CERTIFIED by the state. This ensures that the agency or individual has gone through an entire process, which assures certain levels of standards and staff and agency inspection. For example, certification requires not only fingerprinting but an FBI and Department of Justice background check. It requires a fire inspection of the premises, emergency preparedness plans, and other specific and monitored safety regulations enacted to completely safeguard your child.

Additionally, this NPA certification must be renewed each year.

Children' Speech Care Center is a certified NPA and a copy of the Certification document is posted in our lobby.

Unlike insurance compensation, the term of assistance for NPA is limited only to the time mutually agreed to by you and the school district. This is a very worthwhile avenue to pursue, and under very special conditions, it is possible that your child may qualify for NPA assistance.

(http://www.lao.ca.gov/special_education_0998/special_ed_nonpublic_by_air.pdf)

Basically NPA means that an “outside-the-school-system” agency is allowed to treat children that for some reason cannot be appropriately be treated at the school they attend. There are several reasons why this may occur. For example, the district may not have enough speech pathologists to provide services at your school.

Getting your child qualified generally falls into two categories, simple and very complex. The circumstances cannot be fully explored here and we recommend you explore this option with your school and/or clinic or consulting agency. At times other resources, such as the internet, other parents/parent groups (geared to educate parents on disabilities and educational options), a professional advocate or a specialized attorney, may be helpful in assisting you in the investigation of this option and the determination of the appropriateness of its exploration.

Regional Centers

The Regional Centers are private, not-for-profit corporations contracting with the State of California for the provision of services to persons with developmental disabilities pursuant to the Lanterman Act.

http://www.dds.cahwnet.gov/Publications/Main/LantermanActGuide.pdf

The following is a quote from www.hddf.com. "Any person believed to be developmentally disabled (mental retardation, cerebral palsy, epilepsy, autism or other handicapping condition found to be closely related to mental retardation or to require similar care) is eligible to receive free diagnosis and assessment services. In order to be eligible for on-going services, the person must be found to have a developmental disability which occurred prior to the age of eighteen and which constitutes a substantial handicap. In addition, early intervention services can be provided to infants between birth and three years of age who are believed to be at high risk of having a developmental disability. Further, pre-natal diagnosis and other genetic counseling services can be provided to pregnant women who are believed to be at risk of giving birth to a child with a developmental disability."

As you can see, this can be a very valuable resource for you. We strongly suggest that you visit the site above to gain a better understanding of how the Regional Center works.

As mentioned earlier, they can provide an evaluation free of charge. However, they do not provide speech and language therapy directly, but they do refer and contract out for these services.

Our clinic is contracted to provide speech/language and social skill group services for the local Regional Centers. If you qualify and would like Children’s Speech Care Center to provide therapy, simply inform your caseworker. Please keep in mind that we do have a limited number of spots available for private therapy. Our Social Skills/Play Groups are much more flexible and are forming all the time.

There are limitations and requirements that must be met and you should consult with a caseworker to find out your child's eligibility for services.

The Regional Centers http://www.arcanet.org/index.htm are a very good community resource. By visiting their Website, you can conduct research at the various locations. The above site will provide the names, locations, and areas served by the local Regional Centers.

Children's Speech Care Center has seen children from the following Regional Centers:

Harbor Regional Center: http://www.hddf.com/menu.htm
Westside Regional Center: http://www.westsiderc.org/client/index.html
Lanterman Regional Center: http://www.lanterman.org/
South Central Los Angeles Regional Center: http://www.sclarc.org/

Enrolling your child in a Regional Center

Generally, the population we see at our clinic for individual speech/language services for the Regional Centers ranges from birth to three years of age. The children we see for Social Skills Groups that are funded by Regional centers are typically between the ages of four to twelve years.

However, the population served by the Regional Centers through other organizations is broader than this and includes adults.

In our case Regional Center pays 100% of the cost of therapy so long as your child qualifies. For information on qualification and further information, please visit the individual sites of any Regional Center that is located closest to you.

Other avenues for financial assistance

There are alternative avenues of help. Locating these may prove to be a challenge. We suggest that you consult with the Department of Social Services, the Department of Health and Human Services, and even internet sites for useful tips on how to receive financial assistance for various diagnoses, specific areas, etc.

Some of these agencies can point you to special funds and scholarships that have been set-up to help children with various difficulties.

At this writing, we are in the process of negotiating arrangements with a local financial institution to provide loans to parents who qualify for assistance.

You may wish to contact Bob Alba, our Director of Operations, and check the status of this project or obtain a financial assistance application from him.