1.Private Insurance Companies: Private agencies cover employees, families and individuals. They have a system of professionals within their network or will pay for patients to see specialists or doctors of their choice. Private insurances often follow the same guidance as Medicare. An SLP will come in contact with these by becoming a preferred care provider.

2. Health Maintenance Organizations: HMO’s have contracts with many employees, for example university, state, families, and individuals. Like Private insurance Companies, they have a network of professionals within their system and establish links to specific specialists to provide health care. Patients choose a primary care physician in the network, but cannot choose their specialists. Only if SLP’s are within the network or critical path may they see patient’s from HMO’s.

 
3. Medicare: The country’s federal health insurance program for people age 65 or older, for certain people with disabilities who are under 65 and people of any age who have permanent kidney failure. Medicare has two parts, part A and part B:

Part A-covers hospitalization, skilled nursing facility care, home health care, hospice care, if a patient needs blood from a hospital or skilled nursing facility.

Part B-will cover medical expenses, inpatient or outpatient expenses, clinical laboratory services, home health care, ambulatory surgical services. SLP’s will see patients under Part B of Medicare in the hospital, in a skilled nursing facility, or homehealth care situation. An audiologist would come in contact with them to test for and maintain their hearing aids.

 
4. Medicaid: The state’s health insurance program for people under 18, over 65, those disabled from work 12 or more months, and pregnant women. Medicaid only covers people whose income and assets under a specific amount. SLP’s would see patients who qualify for Medicaid through the public schools, in private clinics, in hospitals, or if they are referred through an HMO or private insurance. Medicaid will only pay up to a certain amount for any specialist service no matter what an SLP bills for.

 
5. Hospice Care: Under Medicare, hospice is primarily a program of care delivered in the patient’s home to those who have an incurable disease with a very limited life expectancy. An SLP might work with patients who have fatal, incurable diseases in the patient’s home.

 
Important Facts about Billing
 

1. The insurance card number for any type of insurance (Medicaid, Medicare, private) must be valid or you will not get paid. There is a 1-800 number available so that validity can be checked. Your company will give you access to this number.
2. All permission from parents or physician must be given.
3. When dealing with Medicaid, got through the primary insurance (if they have any private) before filing with Medicaid.
4. Medicare is the opposite, it is the primary insurance while the private insurance is secondary. File with Medicare, then the private.
5. You must have a doctor’s permission before evaluating, or the evaluation will be invalid. This is true even if the patient is currently enrolled in therapy and you are simply re-evaluating.
6. HMO patients must have a written referral number with them to be paid.
7. Daily or session notes must be taken. These are turned in at the end of each month. These are important to show validity of your therapy to insurance companies.
8. At month end ( or at the end of the specified therapy time period) a report is written for each client and turned into billing office for Medicaid or other insurance approval. Many times, Medicaid or HMOs will be more strict with reports than private insurances.
9. End of month matrix is used to summarize clients seen and amount billed. This is how you will be paid at the end of the month.
10. Much billing can be done electronically.
11. Medicaid, Medicare, and many private insurances use the HICF form for billing.

CPT Codes: (Current Procedural Terminology) CPT codes are created by a national committee of Health Care Organizations and used in every state. They describe and require specific services and treatments to be rendered by professionals. SLP’s should be familiar with these codes in order to provide treatment and bill for treatments. For example: if the code for "diagnostics" is 99250, SLP’s are accountable in their SOAP notes to describe the evaluation and findings. Health Care Organizations would receive a bill with this code on in and pay an SLP only for the amount that matches 99250. SLP’s and their office staff should be familiar with the procedures described in these codes. The codes are examined during an audit situation.

• must be measurable
• must be specific and objective
• no more than a specified number of goals
• Goals are reset every 6 months or specified time period. This must be taken into consideration because you can’t reevaluate before this time period.

Differences in Practice
 

Hospital or School – Salary payment, not by clients seen or how long they are seen. The validity of payment is handled prior to seeing clients. It is the clinician’s responsibility to keep track of visits and matrixes, but not other paperwork or permission.

Private Therapy—The clinician takes care of billing, validity, and permission. You are paid by sessions, not salary.

Glossary:

 
approved amount: the amount an insurance, state, or federal agency determines to be reasonable for a service that is covered by their policy. It may be less than the actual amount charged. For many services, including doctor or SLP services, the approved amount is taken from a fee schedule that assigns a dollar value to all. These values are designated by national CPT codes.
 

assignment: an arrangement whereby a doctor or specialist agrees to accept the Medicare/Medicaid-approved amount as full payment for services. For example, Medicare usually pays 80 percent of the approved amount directly to the specialist and the patient or private insurance company pays the other 20 percent.
 

beneficiary: an insured or covered individual or patient

 
coinsurance: the portion or percentage of the Medicare/Medicaid-approved amount that either a patient or other insurance will be responsible for paying.

 
deductible: the amount of expense a beneficiary (patient) must pay before an insurance agency begins payment for covered services.
 

excess charge: the difference between the agency-approved amount for a service and the actual charge, if the actual charge is more than the approved amount.

 
limiting charge: the maximum amount a doctor or specialist may charge a Medicare/Medicaid beneficiary for a covered service if the specialist does not accept assignment of the Medicare/Medicaid claim. The limit is 15 percent about the agency's approved amount for a particular service.
 

medigap insurance: these policies are sold by private insurance companies. They are specifically designed to help pay health care expenses either not covered or not fully covered by Medicare.
 

participating doctor or specialist: a doctor or health care provider who agrees to accept assignment on all Medicare/Medicaid claims.

 
Important Numbers to contact:
 

Carolina Access Medicaid 1-800-672-3077

Durable Medical Equipment Regional Carriers 1-800-213-5452

Federal Medicare Claims (North Carolina, NC) 1-919-470-6599

Health Care Financing Administration Regional Office (Atlanta, Ga.) 1-404-331-2044

Kaiser Permanent Membership Services 1-800-221-2131

Medicare Carriers-CIGNA 1-800-672-3071

North Carolina-Insurance counseling general info. 1-800-820-1202

Peer Review Organizations (PRO's) Medical Review of NC 1-800-682-2044

Signa Health Care, Medicaid 1-800-672-3071

Social Security Administration 1-800-772-1213

 
world wide web links:

Healthcare Financing Administration