Insurance Reimbursement Guide

Diane Lewis, MA, CCC-SLP is extremely appreciative of the outstanding efforts the families make each month to stay current with their payments.  Several things have come to my attention that might make it easier to not only get paid in a timely fashion, but to, also, possibly get paid more per session.

  • Send in your Diane Lewis, MA, CCC-SLP Invoices in to your insurance carrier as quickly as possible;
  • Be sure that all requests on behalf of your insurance carrier are submitted as quickly as possible; the specific items on the inquiry are the only things that need to be addressed;
  • Find out what percent above the 100% Medicare reimburses for your specific policy.  Some companies pay as much as 140% of the usual and customary for these amounts, therefore, if the Medicare usual and customary for Code 92507 is $75.00 and your carrier pays 140% of that, then you’d be entitled to receive $105.00 for that Code;
  • Look into whether or not your insurance company pays by the Hour or the Unit and for which you’d be reimbursed at a higher rate for;
  • Finally, check to see which of the following Codes your insurance company would recognize and what the usually and customary amounts are as well as the percent they allow.  If there are other codes not listed here that you would like us to use, do let Diane Lewis, MA, CCC-SLP know.
  1. 92507 Speech-Language Therapy-Individual
  2. 92508 Speech-Language Therapy-Group
  3. 97799 Neurodevelopmental Treatment
  4. 97530 Functional Activities
  5. 97110 Therapeutic Exercise
  6. 92526 Oral-Motor/Feeding
  7. 90070 Educational Consultation
  8. 92506 Initial Comprehensive Evaluation
  9. 90887 Interpretation and Written Report
  • Let us know if you want Hour changed to Unit and if you’d like to try to change the Codes.  If you’d like to change the Codes, discuss with your therapist which codes you’d like to use and exactly how you’d like to divide the hours.
  • There are laws in both DC and Maryland which state that all children are entitled to habilitative OT, PT and ST which means that if your insurance is underwritten in either of these jurisdictions, they may not exclude reimbursing you for Diane Lewis, MA, CCC-SLP's services.

Diane Lewis, MA, CCC-SLP is committed to helping the families with this process.

Helpful Websites:

Understanding health insurance plans can be confusing to most consumers. Many don't know where to look or whom to contact for information on the coverage of speech-language pathology services, audiology services and hearing aids, let alone how to interpret the coverage guidelines. ASHA has developed this site to help you, as a consumer, understand your health plan as well as provide further contacts to assist you in understanding and obtaining the coverage you need to receive speech and hearing services.

From the TACA website – “Insurance For Beginners” (mostly geared toward Autism but could be helpful to many)

From the TACA website – “How to Start Working With Your Insurance Company” (mostly geared toward Autism but could be helpful to many)

From the TACA website – “Appealing Insurance Denials” (mostly geared toward Autism but could be helpful to many)

From the TACA website – variety of great links for Autism insurance resources

Other Helpful Info

What you can do

Look for coverage of all health related services under the major medical section of a traditional health insurance policy, or review the benefits booklet provided by your preferred provided organization (PPO), health maintenance organization (HMO), or self- insured employer. Your employee benefits manager is usually an excellent source of information about your health care coverage. There may not be a specific reference to speech-language pathology and occupational therapy. Look for terms such as "speech pathology," "speech therapy," or "hearing care." Speech-language therapy and occupational therapy may also be included in references to "rehabilitation services," "physical therapy," or "other medically necessary services or therapies."

Next Steps

Check for coverage limits and exclusions. Check to see if both evaluation and therapy services are covered. If possible, get clarification of your coverage in writing.

Getting Your Health Plan to Pay

Your therapy provider may be able to help assist you in receiving reimbursement for services rendered that are covered under your policy. If your insurance company denies coverage for services, you should appeal the decision if the plan indicated that the service was covered. Let your therapy provider know that you have been denied.

Ask your physician to write a letter in support of coverage for the speech-language therapy and occupational therapy services received. In your appeal letter, point out statements in the insurance policy or benefits booklet that make you think these services are covered, for example, "other medically necessary services."

(From http://www.sps-atlanta.com/)

  • When parents call the insurance company regarding coverage of therapy services, there are several important questions they need to ask:

1. My child is ____old. Does our policy cover his speech services?
2. What conditions will insurance specifically cover?
3. What ICD-9 (diagnosis) codes and CPT (treatment) codes are covered for reimbursement?
4. Do I need to obtain a prescription for therapy services?
5. Do I need to obtain precertification for therapy services?
6. Which conditions are specifically excluded from treatment?
7. How many sessions will insurance cover? Is there a time limit?
8. Do I have a deductible or co-pay?
9. Do I need to schedule all of the visits by a certain date?
10. Does insurance cover out of network therapy services?
11. How do I get reimbursed for out of pocket therapy expenses? What do I need to provide the insurance company with?