Funding a Speech Generating
What YOU Need to Know!
The success of your funding request for an augmentative and alternative communication (AAC) system depends in part on the quality of the written report. Most third party payers (insurance companies, HMOs) apply the Medicare requirements to review funding requests. Medicare requirements support the medical necessity of an AAC system as well as evidence of an individual’s ability to benefit from a speech generating device (SGD).
Medicare requires that a speech-language pathologist (SLP) conduct, write, and sign the recommendations for specific AAC equipment and forward it to your physician for the agreement of medical necessity. This does not mean that other professionals have not participated in your AAC assessment. HOWEVER, this does mean that a representative of the company that manufacturers or distributes the prescribed AAC system DID NOT conduct the assessment.
The American Speech-Language-Hearing Association (ASHA) is the credentialing organization for speech-language pathologists and audiologists. The Ad Hoc Committee on Medicare (ASHA, 2002) reported that a large number of SGD funding requests submitted to Medicare failed to contain the needed requirements, thus compromising the perceived benefit of the SGD. The committee recommended updating the education of SLPs to improve knowledge and skills related to the SGD assessment and report writing processes.
Given the importance of the funding request, you may wish to ask the SLP the following questions:
• Are you familiar with the Medicare requirements and paperwork for a SGD?
• How many AAC assessment and funding requests have you completed for persons with my disability?
• What third-party payers have approved funding for your clients with my diagnosis?
• What is your approval rate for funding requests?
• In your experience, how long does it take before the physician is notified about the outcome of the SGD funding request?
AAC manufacturers frequently have personnel who are helpful in providing information about the funding process. AAC manufacturers want to make the funding process as easy as possible for you. However, AAC manufacturers should not be used to write the SGD funding request. Finally, more reviewers are becoming savvy to the AAC manufacturer’s SGD report-writing templates being used to support a funding request. In many instances templates do not contain the required justification needed to show the following:
1. A full-range of AAC systems was trialed sufficiently to make the selection, e.g. the individual and family were not fully informed of all the available options.
2. Clinical evidence supporting the use of the selected SGD was not included and/or evidence comparing the performance among the trial SGD was not included.
3. The request contains errors with word substitutions that indicate the report and text were used for another individual or more.
Remember: only your SLP can conduct the assessment and write the report to request your SGD. However, other professionals such as an Occupational or Physical Therapist or Rehabilitation Engineer may be assisting in your AAC assessment. Representatives of the AAC manufacturer can assist in demonstrating and customizing the equipment to meet your personal needs and to ensure that your funding paperwork is complete. Your physician still needs to receive a copy of the report and sign a form verifying medical necessity. In many cases, your personal attention to obtaining the physician's signature is advised.
A word of caution for persons with ALS or other degenerative diseases: Medicare and most insurance companies will not fund SGDs once a person moves to a nursing home. In addition, requests will be denied as soon as Hospice paperwork has been signed. Therefore, timely completion of a funding request may be in your best interest as you start to consider alternative living arrangements.
AAC Institute resources to support your funding request:
ICAN™ Talk Clinics of the AAC Institute conduct workshops on the comprehensive AAC assessment and SGD Funding processes that are geared to various AAC stakeholder groups. Please, call the clinic if you are interested in organizing a workshop or seminar for your organization or region by calling 412-402-0900.
Additional AAC Institute Resources
• How to support your request for a SGD
• Requirements for a Funding Request for a SGD
• Frequently Asked Questions about SGD Funding
• New E-codes replace K-codes
• Medicare Fee Schedule (Lasker)