Understanding Insurance
for Speech-Language Therapy
Your second most important decision
The most important decision you will make is to get help for you or your child. The second most important decision is selecting where you would go for speech and language therapy.
There are a number of criteria you will want to address in order to find the best place to have your child treated for his/her speech and language challenges.
Our Treatment Philosophy:
Our clinic is known as a family-based treatment center, with the family considered an essential part of the treatment team. It is our philosophy that the child and their family are integral parts to habilitation or rehabilitation. Assessments and treatment plans include feedback from parents and/or primary caregivers. The parents are primary decision-makers in the development of a treatment plan and in the child’s actual treatment. They will also be guided in understanding their child’s issues and in how to assist with their child’s intervention to carryover goals and new learning at home, school and in the community.
We also work as a team with all the members of your child’s education and care, as decided by the family and therapist. We use assessments, reports and observations from other professionals in the child’s life, including, for example, physicians, teachers, aides, psychologists, psychiatrists, educational therapists, tutors, occupational therapists, and physical therapists. We will also participate with other team members to coordinate goals and provide feedback and education, as appropriate. We welcome other team members to educate us in their various disciplines and in their specific work with your child.
All our therapists are specialists in pediatric speech/language therapy. They are well educated in a number of treatment interventions and techniques which will assist them in treating your child’s particular issues or disability but also in meeting the needs of your child’s personality and learning style. We do not believe in a “one size fits all” approach. This is the reason for the therapists being well versed in a number of techniques and types of intervention for various problems. Techniques include, but are not limited to, direct teaching and skill building with table top activities, floor play and play-based therapy, use of a naturalistic language approach, computer activities, and reading and writing for older students, as appropriate.
Pediatric Speech and Language is our primary focus:
We are focused on optimizing your child’s Speech and Language skills for use in the real world. All aspects of your child’s growth, development and learning are important, and it is our goal to help your child actualize their potential as a whole. However, we specialize in speech/language and are focused on applying all our knowledge to your child’s ability to communicate. We will work as a team to build their speech/language and educate everyone involved in each aspect of your child’s communication. Further, our programs are customized for each patient, simply because we do not believe one program or one approach is realistic in the complex world of communication.
Our Shared Foundation:
We begin by forming a partnership with you and your child.
Our clinic is dedicated to providing your child with the best possible customized care and support concerning every aspect of Speech and Language Pathology. We believe our assistance will significantly contribute to your child reaching their full potential as a productive, happy and integrated member of the community for the rest of their lives. We believe in seeing your child as a “whole” individual, and maximizing their ability to communicate in the various aspects of their lives.
Our Basic Approach:
Phase One: Assessment
An assessment is the procedure by which we gather specific information about your child’s levels of performance in speech and/or language. We conduct a comprehensive, individualized evaluation to determine the type of challenge(s) your child faces. This includes assessments of strengths, weaknesses, and learning styles. Procedures to acquire this information may include clinical interview with the parent(s) and/or other caregivers, as appropriate, parent questionnaires, informal observations in natural communication situations and/or play (e.g., interview and/or observation in play and/or conversation), use of records/reports from other professionals, and formal and informal testing.
Formal testing consists of administering standardized tests, which have been standardized on children and/or adolescents and are suitable for your child’s chronological age. Formal testing may include, but is not limited to, tests that utilize visual (e.g., objects, pictures, written words/sentences) and verbal stimuli (with or without pictures/objects/written words/sentences) to determine speech and/or language abilities. Informal testing may include non-standardized clinical observations of your child in conversation and/or play and use of other informal materials and procedures (e.g., pictures, blocks, puzzles, reading material, written samples) to probe certain skill levels or skill mastery.
A full assessment typically ranges from one and a half hours to three hours depending on your child’s age and issues. Assessments are performed in a manner which allows your child to feel at ease and comfortable. For the young child, the evaluation is frequently play based and/or may involve play breaks and reinforcers (rewards). A formal speech/language evaluation report will be written after the testing is completed. This report will outline all the measures used, your child’s performance levels and speech/language diagnoses. It will show a profile of strengths and weaknesses, clarify where your child needs assistance, and include an individualized treatment plan.
Speech and Language insurance benefits are often very limited, so it is vital that you first obtain a copy of your policy and carefully review what benefits are available to you. Whether you have a private policy or a policy that is provided by you or your spouse’s employer, assistance is available to you to help you understand the language of the policy which is often confusing to the typical lay person.
Most private clinics are also limited in the types of insurance they can accept. If they can bill your insurance company directly, please remember that this is done as a courtesy. If your insurance company is late in payment or your claim is denied, you will be responsible for making the payment within the clinic’s standard payment terms.
Lynne Alba Speech Therapy Solutions accepts several types of insurance. Please contact us for a list of insurances we accept. Our office will be able to checked your insurance for eligibility and benefits prior to service
Insurance Coverage Limitations
Many insurance companies will only cover what is known as “Medically Necessary” treatment. Regrettably, Speech-Language Therapy is not always considered medically necessary. This is because a good number of issues involving speech and language are considered “developmental” in nature, especially in children.
There are some general exceptions. For instance, Autism is often covered. Speech and language issues caused by Otitis Media (ear infections) are often covered. In any event, it is wise to completely understand what coverage is provided by your specific plan.
The very best website we have found for obtaining informative material regarding insurance plans is the American Speech and Hearing Association. Be sure to follow the internal links to various important subjects. They have an excellent response letter for denials.
Make sure to consult your plan to see if you need a doctor’s referral before you can receive services.
Speech and Language Services and Insurance
Some of the speech and language ICD-10 (International Classification of Diseases, Tenth Revision) billing codes frequently used are the following:
F80.1: Phonological disorder
F80.4: Mixed receptive-expressive language disorder
F80.1: Expressive language disorder
F80.4: Speech and language development delay due to hearing loss
F80.81: Childhood onset fluency disorder
F98.5 Adult onset fluency disorder
R47.01 Aphasia
Please click on “Diagnosis we see” to obtain a full list of the over 100 diagnosis we treat.
This is not an all-inclusive list of speech-language diagnostic codes. Further, should you or your child have other specific conditions, such as autism spectrum disorder (ICD-10 code F84.0), which include a speech-language diagnosis, insurance may fund speech-language services.
Insurance, in general, is reserved for rehabilitative services. That is, insurance will cover payment to restore a faculty that a patient had but lost because of an accident, illness or injury.
Medical Savings Account Program
Two programs that are becoming increasingly popular are the Health Savings Account (HSA) and the Medical Savings Account (MSA). These programs are sponsored and
managed by employers. Typically, to deduct medical expenses, you are only allowed to deduct any amount over 7½ % of your adjusted gross income. So, for a family that has a combined adjusted gross income (AGI) of $60,000 per year, the first *$4,500 dollars would be excluded from your allowable medical deduction. By using the HSA or MSA program, it is possible that you could set aside the *$4,500 as pre-tax dollars. Since this reduces your AGI, you save an additional *$1 ,500 in taxes. You could now apply the total of $6,000 to your medical costs. You can carryover any amount not used in the current year to the next year. If you leave your place of employment, your medical savings account is transferable. In addition, this program allows you to pay for other medically related items that are not paid by insurance. Dollar amounts are provided as examples only.
You can see that families of Special Needs children who have their children in multiple therapies could be well served by this plan.
Like all programs, it is vital that you check with your employer to make sure the plan is available to you. The provisions of the plan have recently changed, and many employers may not be familiar with these changes.
IRS Publication #969 entitled Health Savings Accounts and Other Tax-Favored Health Plans is a good place to start your investigation into the program. This free publication is available at www.irs.gov. These plans are somewhat complicated, so we cannot stress enough that you must take the time to read the IRS provisions and make sure your employer is versed in their details.
You are your own best advocate
We are all aware of the growing complexity of healthcare and we are sensitive to the ever increasing costs that come with it. It is for this reason all of us must become better educated in understanding medical insurance, in general, and our specific plans, in particular.
Without a doubt, the best advice that we have received from experts in the field is that a parent must adopt a posture of becoming a strong advocate for their children.
Insurance will often deny services upon your first request. Sometimes this is warranted, but you do have the right to appeal. An “appeal letter” can be found on ASHA’s Web site.
We would be happy to discuss your case with you and, based on our experience, give you an opinion about pursuing the matter further. (Bob Alba 310-856-8528)
We are not legal counselors regarding insurance nor are we parent advocates, but we have had a number of years in interacting with the insurance industry with regard to the services we provide and we can provide you with our input.
As indicated in this brochure, it can be very beneficial for you to take the time to look at the information available on the American Speech and Hearing Association’s (ASHA) website regarding insurance.
The Internet is a great resource
We have found that the Internet is a great resource for helping to understand insurance, getting additional help and finding advocacy and legal assistance. We often enter the search with terms such as: insurance and autism+California or other terms like this. Often your own insurance provider will also have a website that can be of great help.
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