Medicaid Guidance for School-Based Speech-Language Pathology Services: Addressing the “Under the Direction of” Rule


Working Group on Medicaid Reimbursement

About this Document

This guidelines document is an official policy of the American Speech-Language-Hearing Association (ASHA) and was prepared by ASHA's Working Group on Medicaid Reimbursement as part of the 2005 Focused Initiative on Reimbursement. Members of the Working Group included Melanie Frazek, Amy Lyle, Lissa Power-deFur (chair), Ruth Peaper, and Kathleen Whitmire (staff coordinator). Celia Hooper, vice president for professional practices in speech-language pathology (2003–2005), served as monitoring vice president.


Medicaid regulations for reimbursement of speech-language services[1] provided in school settings are specific regarding the qualifications of the speech-language pathologist providing those services, but offer no specific direction regarding reimbursement for services provided by personnel not meeting those standards. Personnel who do not meet the qualification standards may provide services “under the direction of” a qualified speech-language pathologist. In the absence of specific federal guidance on the requirements for “under the direction of” services, states develop their own specific criteria, resulting in great differences nationwide in the qualifications of personnel who are providing services for Medicaid billing in the schools and creating the potential for several untenable legal, ethical, and workload situations for speech-language pathologists. To minimize any adverse effect on students receiving services in the school and any legal, ethical, and workload impact on the supervising speech-language pathologist, the ASHA Working Group on Medicaid Reimbursement developed a series of four documents (position statement, technical report, guidelines, and knowledge and skills). These documents are designed to assist speech-language pathologists and school administrators in implementing special education Medicaid billing programs that ensure students are served in a “safe and efficient manner in accordance with accepted standards of practice” (Medicaid; U.S. Department of Health and Human Services [DHHS], 2004) and Principle I of the ASHA Code of Ethics, which states that “individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally” (ASHA, 2003a).

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Medicaid is a federal-state program. States must adhere to all federal requirements, yet have authority to establish parameters of each state's program. Each state prepares a State Plan detailing its Medicaid program for approval by the Centers for Medicare and Medicaid Services (CMS). CMS is organized by region, with approval occurring at the regional office. As a result, despite CMS's oversight authority, the specific policies and procedures regarding Medicaid implementation vary from state to state.

The Medicaid program is found in Titles XIX and XXI of the Social Security Act. The Medicaid program for children requires identification of children in need of health services and provision of services to screen, diagnose, and treat such children. Medicaid's health services include speech-language pathology, audiology, occupational therapy, physical therapy, and nursing services. Because the tasks of identifying, diagnosing, and treating are fundamental to public school special education programs, there had been a growing realization of a possible link between Medicaid and special education. School special education programs could provide valuable Medicaid services and Medicaid could provide a source of funding for schools.

In 1988, Congress clarified the relationship between Medicaid and public education by adding language to the Medicare Catastrophic Coverage Act that prohibited the restriction of Medicaid funds to reimbursement of services outlined in the individualized education program (IEP) of a child with a disability. The Congressional Conference Committee Report specified that although the state education agencies are financially responsible for educational services, in the case of a Medicaid-eligible child with disabilities, state Medicaid agencies remain responsible for the “related services” identified in the child's IEP if those services are covered under the state's Medicaid plan (see ASHA, 1991).

The 1997 Reauthorization of the Individuals with Disabilities Education Act (IDEA 1997; U.S. Department of Education, 1999) recognized the ability of school districts to bill Medicaid for certain special education services and included parental protections regarding access to special education services. IDEA 1997 regulations ensure that evaluations and IEP-specified services will be provided to the child by qualified special education providers, as defined by that state's education agency. Neither IDEA 1997 nor the 2004 reauthorization of IDEA address specific qualification standards, nor do they require state education agencies to establish the same standard as the state's Medicaid agency.

In the past decade, another facet of the Medicaid program has been implemented in many school districts, namely, that of administrative claiming. This program enables government entities (such as local school districts) to claim a portion of the administrative time spent by personnel that addresses the needs of children eligible for Medicaid. This is a distinctly different program from the special education billing program and is not the topic of this guidelines document.

One of the challenges of applying the Medicaid qualification and supervision requirements to the public education environment is the difference between qualifications and standards for medical providers versus educational providers. Medicaid sets provider qualification standards at the federal level that apply to all states. In contrast, provider qualification standards in education are the purview of each state. (The ASHA technical report [ ASHA, 2004b] contains further discussion of the Medicaid and educational requirements regarding personnel qualifications.) Table 1 displays the authority of the two federal agencies and their respective state agencies. The various requirements (Medicaid State Plan, education regulations, and policies) are found in public documents that are available at federal and state government Web sites. However, the requirements specific to the special education Medicaid billing program are embedded in large documents and will require searching to find the specific language. Frequently, staff at the state Medicaid and education agencies can provide assistance in identifying the pertinent requirements.

Table 1.

  Medicaid Education Federal authorizing legislation Title XIX and XXI of the Social Security Act Individuals with Disabilities Educational Improvement Act Federal administrative agency Centers for Medicare and Medicaid Services (CMS) U.S. Department of Education State administrative agency State Medicaid agency State education agency Source of requirements for provider qualifications Medicaid State Plan State teacher licensure/certification regulations Source of requirements for documentation requirements Medicaid State Plan State special education regulations

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Provider Qualifications

The state-to-state variability in Medicaid programs is evident in the definition of personnel who are deemed by the state to be qualified to provide speech-language pathology services. Each state establishes its own requirements for personnel qualifications, using the federal standard as the basis for state laws and regulations. States may also define the provision of services by lesser or unqualified personnel when they are “under the direction of” qualified personnel. However, states' Medicaid State Plans are often silent on the qualifications of providers who serve “under the direction of” qualified providers. Medicaid regulations also give states the authority to establish the qualification standards of persons who determine the medical necessity of the service.

Federal Medicaid regulations define a qualified speech-language pathologist as “…an individual who—

  1. Has a certificate of clinical competence from the American Speech [Language] Hearing Association;

  2. Has completed the equivalent educational requirement and work experience necessary for the certificate; or

  3. Has completed the academic program and is acquiring supervised work experience to qualify for the certificate.” (U.S. DHHS, 2004, 42 CFR 440.110 (c) (ii))

State standards for “equivalent” are set by each state's Medicaid agency. CMS requires that each state justify the equivalency determination and submit the opinion of the state's attorney general regarding equivalency. Medicaid standards are generally based on that state's audiology and speech-language pathology licensing agency and occasionally reflect the state's Board of Education standards for teacher certification or licensure. CMS must approve any determination of equivalency.

As each school district enrolls with the state Medicaid office to serve as a Medicaid provider, the Medicaid agency will implement its procedure for assuring that each service provider, including speech-language pathologists, meets that state's qualification requirements. Districts will have to maintain documentation of the speech-language pathologists' current ASHA certification and state licenses.

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“Under the Direction of” Rule

Federal Medicaid regulation addresses provisions of services by lesser or unqualified speech-language pathologists (or audiologists):

Services for individuals with speech, hearing, and language disorders means diagnostic, screening, preventive, or corrective services provided by or under the direction of a speech[-language] pathologist or audiologist for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law ( U.S. DHHS, 2004, 42 CFR 440.110 (c) (1))

CMS has offered minimal guidance to states regarding implementation of the “under the direction of” provision. CMS guidance for audiology was published in May 2004, offering clarification for services provided “under the direction of” a federally qualified audiologist ( U.S. DHHS, 2004). The only guidance specific to speech-language pathology is found in a regional policy clarification, which does not have nationwide application. See the companion technical report ( ASHA, 2004b) for further discussion of these two policy interpretations. The position statement ( ASHA, 2004a) provides ASHA's position regarding the qualification requirements for personnel providing services “under the direction of” and for personnel who provide that direction.

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Medicaid Documentation Requirements

Medicaid guidance indicates that services provided to children must be medically necessary. This standard is verified in “referral by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under state law” (U.S. DHHS, 2004, 44 CFR Section 440.120 (c) (i)). Depending on the state's Medicaid State Plan, this requirement may be met by a speech-language pathologist who is licensed under state law. Speech-language pathologists should contact the Medicaid agency to determine the state's policy. A copy of this determination of medical necessity, frequently termed physician authorization, must be maintained in each student's file.

Districts must be sure to adhere to the Medicaid documentation requirements. Districts should review their state's Medicaid State Plan and federal requirements to determine specific requirements related to the following:

  • Claim only for the units of direct services provided, not to exceed those established by the IEP and excluding consultation.

  • Claim only for group therapy that meets Medicaid requirements in terms of size.

  • Claim only for services with documented progress, as Medicaid generally does not pay for maintenance.

  • Claim only for services provided to children who were eligible for Medicaid at the time services were provided (this will involve maintaining a detailed tracking system regarding students' eligibility, as it may fluctuate from month to month).

  • Claim only for services provided to children for whom the district has authorization from the children's parents to release information to Medicaid.

  • Maintain treatment notes and service logs, detailing the procedure, diagnosis, date, and length of session.

  • Document services provided “under the direction of,” including “sign off” by qualified personnel at the schedule required by the state Medicaid agency.

School districts are subject to Medicaid audits at any time. Each state's Medicaid agency has the authority to deny claims retroactively and require payback of Medicaid payments. In addition, if the Medicaid audit indicates that fraud took place, districts may be liable for fines for fraudulent claiming. The nature of school district budgeting is such that any payback to Medicaid would be considered a new expenditure and may require authorization of the local school board prior to payment. It behooves speech-language pathologists to work with their district to ensure that all Medicaid requirements are being met and can sustain an audit successfully, avoiding public identification of the district's audit failure.

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Supervision of Providers Not Meeting Medicaid Requirements

To effectively implement a special education Medicaid billing program that includes billing for services provided by those not meeting the qualification requirements, the district must set up an adequate system for supervision of providers who do not meet Medicaid requirements. This section describes the purpose, the benefits, and the process of “under the direction of” supervision for Medicaid reimbursement in the schools. The following areas are addressed:

  • review of recommended supervisory contacts;

  • purpose of “under the direction of” supervision;

  • opportunity/benefits for schools, personnel, and students;

  • supervisory process; and

  • procedural recommendations.

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Review of Recommended Supervisory Contacts

Supervisors of services for Medicaid reimbursement assume professional, ethical, and legal responsibility for the services billed under their license. School administrators, supervisors, and supervisees should review Medicaid Guidance for Speech-Language Pathology Services: Addressing the “Under the Direction of” Rule [Technical Report] (ASHA, 2004b). This document identifies credentials needed for providers and supervisors, as well as recommended levels of supervisory contacts for Medicaid reimbursement in the schools. Both indirect and direct supervisory contact for each Medicaid-eligible student should be completed at least twice per quarter, with accurate records of supervisory contacts maintained. These recommendations represent the minimum levels of contact needed for a supervisor to have reasonable knowledge of and opportunity to monitor the services being billed under his/her supervision. The length of direct supervision time is not specified but should be adequate for the supervisor to determine that appropriate services are provided. Supervisors must increase the frequency and length of direct and/or indirect contact when supervisees require more support to provide acceptable services.

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Purpose of Supervision for Medicaid-Eligible Students

Although CMS has not defined “under the direction of” for speech-language pathology services, it has offered some guidance on the focus of supervision in the Final Rule for Medicaid Program: Provider Qualifications for Audiologists, stating that audiologists must “ensure beneficiaries are receiving services in a safe and effective manner in accordance with accepted standards of practice” (U.S. DHHS, 2004, 42 CFR 440.110). Supervisors must consider many factors to ensure that the services meet this standard. Supervisory interactions are multilayered in that supervisors address the needs of the supervisee as well as the students they serve. Supervisors facilitate growth of the supervisee and, in some cases, are responsible for evaluation of the supervisee. For example, practicum supervisors of students assign grades, and rehabilitation team leaders or school administrators evaluate professional staff for performance review, which may have merit raise and contract renewal implications. Supervisors also ensure that identified goals are appropriate and that students are making satisfactory progress in meeting established goals.

Qualified speech-language pathologists providing supervision to meet the “under the direction of” requirements for Medicaid-eligible students may or may not have an administrative role in the district. Some supervisors for Medicaid-eligible students may also be program administrators who evaluate the supervisee for performance review. It is possible, however, that many “under the direction of” supervisors will not hold any administrative designation. In fact, union contracts may preclude staff clinicians from assuming administrative functions. Supervisors could be supervising longtime staff colleagues or even more experienced clinicians who do not meet Medicaid criteria as a qualified provider. Supervisor/supervisee scenarios will vary considerably from district to district. Consequently, each district must clearly define the roles and responsibilities of supervisors for Medicaid-eligible students. Supervisors and supervisees must be informed if information from these interactions is to be used in any way for performance review and, if so, how it will be used. Clear communication and mutual trust are crucial foundations of successful supervisory interactions. Explicit policy statements and procedural guidelines will provide a foundation for supervisees and supervisors to build their relationship.

Supervisors signing off on billing forms indicate approval of services provided, rather than evaluation of supervisees. Certainly, the skills of the clinician providing the service are intrinsically linked to the quality of those services. By no means should clinician skills be ignored in determining the appropriateness of the services. Supervisors should consider and address provider skills within the context of providing quality clinical services. The supervisory support provides a unique opportunity for supervisees at any level to target personal goals for improvement and obtain feedback from the supervisor. The question is not whether clinician skills should be considered by the supervisor but rather if, when, and how information about those skills could be included in personnel evaluations of the supervisee. Similarly, the district should also identify if, when, and how it may incorporate the supervisory skills of the supervisor in performance evaluations.

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Benefits for Schools, Personnel, and Students

This supervision mandate for Medicaid reimbursement offers schools a unique opportunity to commit resources and personnel to enhance the overall quality of speech-language services provided to all students in the district. Through the required direct and indirect supervision contacts for Medicaid-eligible children, supervisors and supervisees collaborate to provide quality services for these students. The knowledge and skills gained through this effort can then be applied to all students on the caseload and shared with other speech-language clinicians in the district. When properly implemented, this learning opportunity should be welcomed by the supervisees. New supervisees frequently have questions about appropriate treatment goals and strategies. Even experienced clinicians could benefit from discussing challenging cases with a colleague. Even experienced clinicians may have some aspect of their performance they wish to improve. The Medicaid supervisor can be a resource and a facilitator for change.

Districts supporting the collaborative problem solving efforts of the supervisor and supervisee send a message to all staff that they are committed to best practice. School districts should demonstrate their support by committing some of the substantial revenue received from Medicaid reimbursement to the strengthening of supervisory endeavors. This support may include the following:

  • reducing the supervisor's caseload to accommodate supervisory responsibilities,

  • incorporating time for indirect supervisory contacts into the supervisee's schedule,

  • releasing time/reimbursement for the supervisor to attend workshops or obtain course-work in the supervisory process, and

  • releasing time/reimbursement for supervisees to access needed workshops or courses to support the services they provide.

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The Supervisory Process

As previously described, supervisees who provide services for Medicaid reimbursement will demonstrate a broad range of experience and credentials. Essential to the success of supervisory interactions is the need to match supervisory input with the needs of a given supervisee. Supervisors must become knowledgeable about the background of the individuals they are supervising. To accurately determine supervisee level, supervisors should consider the following for each supervisee:

  • experience with populations/settings,

  • credentials,

  • professional development activities, and

  • supervisee self-analysis of their needs in servicing specific students.

The Continuum Model of Supervision (Anderson, 1988; McCrea & Brasseur, 2003) offers guidance on the nature of supervision appropriate for supervisees at various levels. According to this perspective, supervisee growth is an ongoing process and supervisors must continuously adjust their style to meet the needs of individual supervisees. This model identifies three distinct stages through which supervisees progress, and the supervisory style appropriate for each stage (see Table 2).

Table 2.

Supervisee Level Supervisor Style Evaluation/feedback Direct modeling/instruction Transitional Collaborative Self-supervision Consultative/mentoring

A unique aspect of this supervision model is the fact that all supervisees, even those with considerable experience, will move up and down the continuum as they enter new practice settings, work with new populations, or apply new clinical procedures. Supervisors working with clinicians in the evaluation/feedback stage will provide more explicit evaluation and feedback and may model specific clinical techniques and procedures. For supervisees in the transitional stage, the supervisor and supervisee collaborate to plan, continuously assess, and refine treatment plans and procedures. For supervisees in the self-supervision stage, the supervisor serves more as a consultant, available to act as a “sounding board” or assist the supervisee in problem-solving difficult cases.

Professionals supervising services for Medicaid-eligible students face a unique challenge in that the range of supervisees is broad, possibly extending from speech-language assistants to experienced professionals. Supervisees could become resistant to supervisory input if their experience level and skills are not recognized. Supervisors could also waste valuable time providing direction and feedback in areas where the supervisee may already be proficient. Successful supervisory interaction must begin with a sharing of information to assist both supervisors and supervisees in identifying goals. Supervisors who successfully adjust their supervisory style will avoid creating difficult interactions with experienced supervisees. Supervisees will in turn appreciate validation of their skill level and the opportunity to be an active participant in the process.

Texts on the supervisory process (Dowling, 1992, 2001; Farmer & Farmer, 1989; McCrea & Brasseur, 2003) offer guidance for development of supervisee skills and suggestions for data collection to measure performance. Supervisors should use objective measures when determining if services are meeting acceptable standards of practice, identifying areas for supervisee growth, and monitoring change. During direct observation, supervisors should collect data on the supervisee and student performance and analyze it to determine areas of strength versus areas for skill development. Supervisors who use this model of “evidence-based” supervision ensure that supervisees' assessments are based on objective analysis of their work rather than on subjective judgments.

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Supervision Recommendations: Implementation Strategies

The ASHA position statement addressing Medicaid supervision (ASHA, 2004a) allows supervisors flexibility in how to meet the recommended contacts in the most efficient way possible. For example, if a supervisee is providing group or classroom-based services with multiple Medicaid-eligible students present, observation of the group or classroom session could meet the direct observation requirement for those students. Supervisees and supervisors should also have time during visits to discuss problem cases and review supervisory feedback. Carefully coordinating schedules should allow the supervisee to address both direct and indirect supervision requirements in one visit.

Supervisors must also review relevant documentation for Medicaid-eligible students, including session notes, attendance records, and re-assessment results. This documentation could be shared electronically, assuming the district has implemented sufficient security measures to ensure confidential exchange of this information. Electronic sharing of this paperwork could lessen the amount of time the supervisor may need to be on-site in the supervisee's school setting. The time for paperwork review must be factored into the supervisor's workload, but with electronic sharing the supervisor can determine when this responsibility can best be met. Some conferencing between supervisor and supervisee may also be completed electronically or by phone contacts but should not completely replace face to face meetings. Accurate documentation of all contacts (on-site, electronic, phone) must be maintained.

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Defining Supervision Policies and Procedures

Districts and supervisors working together to develop written guidelines, with well-defined policies and procedures, will ensure successful Medicaid supervision programs. The following areas should be discussed:

  • District Policy Issues

    • Assurance that ASHA-certified speech-language pathologists are under no obligation to assume the role of supervisor for Medicaid reimbursement (unless this was an explicit condition of hiring)

    • Supervisor/supervisee roles within the district's administrative structure. When possible, designate a CCC-SLP as Speech/ Language Program and Medicaid Billing Administrator

    • Supervisor qualifications

    • Supervisor/supervisee responsibilities

    • If , when, and how information from supervisory interactions will be used for performance review

    • How the district will identify Medicaid-eligible students requiring “under the direction of” supervision

    • How the supervisor's workload will be adjusted to accommodate supervisory responsibilities. The policy should recognize that supervisory time may need to be increased if a supervisee believes that IEP goals should be modified.

    • Process to be followed for instances when the supervisor believes a supervisee's skills are lacking and/or the supervisee has not responded to suggestions made by the supervisor (e.g., an action plan identifying specific goals for the supervisee, supports needed, expected timetable for meeting those goals, and consequences if goals are not met)

    • How union requirements (if applicable) and position descriptions have an impact on the supervisor's role

    • Orientation process for new supervisors

    • Orientation process for new supervisees

    • Ongoing review process for district Medicaid policy, as all involved parties should periodically assess established procedures and revise when needed

  • Supervisor and Supervisee Issues

    • Supervisee background to be shared with supervisor, including credentials, prior experience, and professional development activities

  • Medicaid-Eligible Student Issues

    • Evaluation results and IEP for Medicaid-eligible students

    • Expected learning results for student's grade level

Some states may have practice guidelines that address the above issues. Districts should contact their state education agency to determine if such guidelines or policies are available.

Attention to these supervisory issues early in the establishment and implementation of the special education Medicaid billing will minimize the challenges and frustrations faced by district speech-language pathologists and the potential for any negative audit findings by Medicaid.

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Ethical and Legal Issues

Participation in the Medicaid program imposes additional responsibilities and liability on a qualified service provider. Moreover, the legal and ethical liability increases for the school-based speech-language pathologist who agrees to supervise another individual's services for the purpose of Medicaid reimbursement.

Pursuant to Medicaid requirements, speech-language pathologists have the legal responsibility to provide services to Medicaid-eligible children “in a safe and efficient manner in accordance with accepted standards of practice” ( U.S. DHHS, 2004). Additionally, Medicaid allows for the reimbursement of services provided by nonqualified providers so long as said services are “under the direction of a speech-[language] pathologist or audiologist” ( U.S. DHHS, 2004, 42 CFR 440.110(c)(i)). Clearly the supervised services must also be delivered “in a safe and efficient manner in accordance with accepted standards of practice.” These standards of practice refer to the standards held by the profession of speech-language pathology—not the standards of an employment setting. It is not the prerogative of a particular employment setting to carve out exceptions or self-imposed exemptions to a profession's accepted standards of practice.

Therefore, where Medicaid may be limited regarding certain absolute requirements, the speech-language pathologist must look for guidance from the profession. When conflicting information or differing opinions trigger ethical dilemmas, the speech-language pathologist can, and should, obtain guidance from the ASHA Code of Ethics ( 2003a). Above all else, Principle I of the code requires that speech-language pathologists and audiologists hold paramount the welfare of the client being served when making decisions. Refer to ASHA's companion document, Medicaid Guidance for Speech-Language Pathology Services: Addressing the “Under the Direction of” Rule [Technical Report] ( ASHA, 2004b, pp. 9–11), for a review of the legal and ethical issues that arise when supervising another solely for the purposes of Medicaid reimbursement.

In assuming the ethical obligations presented both literally and in the spirit of the Code of Ethics, speech-language pathologists and audiologists also assume a professional obligation “to never transfer ethical responsibilities to employers, administrators, or supervisors” ( Shinn, 2004). To do so either unintentionally or purposefully will not protect the service provider from liability.

Within the context of supervising another's services for Medicaid reimbursement, there are consequences for violations of the rules and regulations. Certainly services not in accordance with accepted standards of practice, inadequately supervised services, and claims for services that were not provided (which may be deemed “not provided” if the documentation is insufficient or nonexistent) could easily result in the school district having to pay back funds received.

Fraudulent billing is a criminal activity. Potential consequences for this conduct are fines and/or incarceration. “In many cases, professional activities that may result in these complaints reflect an ignorance of applied regulation, or direct violation with full knowledge of applied regulations (i.e., Medicare and Medicaid law)” ( ASHA, 1994, pp. 27). The individual service provider should not be so naïve as to think that the employer will bear all responsibility for said criminal conduct.

For either negligent or criminal conduct, the practitioner faces not only the distress and emotional toll of his or her actions, but also the possible loss of livelihood. Under these circumstances, it would not be unrealistic to lose one's professional credentials (e.g., ASHA certification, state license, education agency credential, association memberships).

Therefore, it is critical for the supervising speech-language pathologist to carefully consider whether certain professional activities satisfy the Medicaid rule for services to be performed in a safe and efficient manner in accordance with accepted standards of (professional) practice. If the speech-language pathologist questions the propriety or integrity of a particular task or activity, he or she should contemplate the pertinent ethical responsibilities, including but not limited to holding paramount the welfare of the client being served. Where there is a conflict either in varying regulations or in employer demands, the speech-language pathologist is best advised to follow the higher standard—whether legally or ethically.

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Workload Implications of Medicaid Supervision

Adjusting the Workload for Medicaid Supervision

The provision of “under the direction of” supervision for Medicaid reimbursement imposes additional requirements for both the supervisor and the supervisee in order for Medicaid revenue to be secured in an ethical and compliant manner. It is critical that these direct and indirect requirements, previously discussed in this document, need to be addressed when determining the workload of both parties. Workload refers to all activities required and performed by the service provider, not just the number of students served, commonly referred to as caseload ( ASHA, 2002). In 2002, ASHA divided workload responsibilities into four clusters: (1) direct services to students, (2) indirect services that support students' educational programs, (3) indirect activities that support students in the least restrictive environment and general education curriculum, and (4) activities that support compliance with federal, state, and local mandates. For both parties, the workload responsibilities in Cluster 4 will be expanded and detailed to address Medicaid requirements and ASHA's “under the direction of” guidelines (both direct and indirect supervision). Time requirements for these activities will vary for both parties depending on a variety of factors, such as the credentials/skills of the supervisee, the nature of the clinical task/complexity of cases, and the level of supervision necessary to ensure services consistent with accepted standards of practice delivered in a safe and efficient manner.

As the workload of the supervisee is subsumed within the role of the supervisor, the workload of the supervisee(s) need(s) to be determined prior to that of the supervisor's workload. For the supervisee, the workload responsibilities may include all or some of the tasks detailed within each cluster dependant upon the supervisee's credentials as well as on individual state laws. The supervisee, in coordination with the supervisor, must first identify those workload activities that are specific to him or her and then conduct a workload time survey. Form A from the Implementation Guide: A Workload Analysis Approach for Establishing Speech-Language Caseload Standards in the Schools ( ASHA, 2003b, p. 41) provides a framework, but will need to be expanded to address the specific requirements for Medicaid supervision and documentation to occur in compliance with federal and state mandates. This includes identifying the role, responsibility, and time necessary for direct supervision, indirect supervision, and paperwork specific to Medicaid-eligible students for Medicaid purposes, as well as flexibility to address other needs such as training (disorder-specific or Medicaid documentation related) or meeting with administration regarding practices and implementation of the process. Addressing these areas will ensure that the nature, frequency, and amount of supervision provided are appropriate to ensure quality speech-language services.

Once the workload of the supervisee(s) has been determined, specifically the time necessary to fulfill “under the direction of” requirements, the supervisor's workload can then be established. Similar to that of the supervisee, the supervisor must complete a Workload Analysis Survey, Form A, from the workload analysis implementation guide ( ASHA, 2003b) that encompasses the needs of his or her specific cluster responsibilities as well as the needs of the supervisee(s) assigned to him or her for direct supervision, indirect supervision, paperwork, and miscellaneous other Medicaid related tasks, such as ongoing training in supervision. It is critical for the supervisor to have dedicated time to address “under the direction of” requirements if students are to receive quality intervention. Each supervisor's workload will vary depending on the tasks necessary, the skills of the supervisee, and the number of supervisees one is responsible for.

Establishing an appropriate workload level that is completed within the work week continues to be a professional challenge. Supervision is often an additional task once caseloads are established administratively with no regard to the actual workload. However, there are several examples of how this may be accomplished within our own profession by assigning a time allocation for a specific function and encompassing the entire workload of activities. Portland, Oregon, addressed their workload issues with an alternative 3:1 service delivery model. With this service delivery model, 3 weeks out of each month are devoted to direct intervention with students and the remaining week is allocated for indirect activities, such as paperwork and meetings ( Annett, 2004). Alternative blocks of time for specific functions may also be considered, such as 4 days of therapy, 1 day for paperwork/supervision. Rochester City School District in Rochester, New York, allocates specific time for the supervisor to complete “under the direction of” tasks as well as provides those individuals with a salary stipend. Blosser and Kratcoski ( 1997) developed and implemented, “PACs: A Framework for Determining Appropriate Service Delivery Options.” Within this model, providers (P), activities (A), and contexts (C) are all considered when determining an appropriate service delivery model for a specific student. As the provider is a key component of this model, workload issues are addressed in a proactive manner rather than reactively after the student is assigned to an already existing and full workload. If supervision tasks are unable to be fully completed during the workday, a district may consider an extended workday with a salary increase. Whether implementing one of the above models of workload management or developing a model unique to adistrict, it is essential that clear, concise, and accurate documentation be maintained regarding workload issues. Not only does this documentation highlight the variety of tasks a speech-language pathologist is responsible for, it also highlights the amount of time necessary to ensure compliance.

Documentation can serve as the basis for informed discussions, productive change, and continued advocacy for changes in state Medicaid policy to reduce paperwork burdens (e.g., confidentiality, physician's order, completing for all students vs. Medicaid only). This can be an opportunity to use documented workload to influence state policy and/or local practice in order to establish a reasonable process that is in compliance with Medicaid regulations and is consistent with ethical responsibilities. A focus on the workload that is involved in the supervisory process can help inform policy and practice in order to achieve a reasonable and appropriate process.

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Medicaid billing for special education services can become an opportunity to communicate with administration about speech-language pathology qualification requirements, workloads, and ethics. The challenges surrounding integration of Medicaid billing into existing public school speech-language pathology programs are numerous and can easily make it hard to see this as an opportunity for the district's speech-language program.

School districts throughout the country are facing funding challenges, with a potential negative impact on speech-language pathologists' working conditions. For example, fiscally strapped districts will have more difficulty allocating additional positions in order to lower caseloads, offering salary supplements to persons with the master's degree, providing professional development opportunities, or purchasing sufficient materials (e.g., new editions of assessments) and equipment (e.g., laptop computers for speech-language pathologists or augmentative and alternative communication devices to use diagnostically with students). By participating in the generation of additional revenue sources, speech-language pathologists can be seen by the administration as part of the solution to the fiscal challenges. Such involvement not only adds an additional role of speech-language pathology services as a revenue generator but identifies speech-language pathologists as “team players” who are interested in the greater good of the district. This role can draw attention to the speech-language program and the role of speech-language pathologists that may have previously been unrecognized.

The best opportunity for involvement is during the initial stage of establishing the program. If the program is underway, speech-language pathologists should focus their involvement and advocacy during year-end reviews of the Medicaid billing program. The focus of the speech-language pathologist's involvement should be on educating administrators and advocating for working conditions to improve the speech-language pathologist's ability to meet students' needs and complete the requirements of Medicaid billing.

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Educate Yourself

The first step in advocacy is to fully educate oneself. The special education Medicaid billing program is complicated and, therefore, easily misunderstood. Speech-language pathologists should familiarize themselves with their own state's standards for Medicaid billing in schools. Information can be found at the state Medicaid agency's Web site and, frequently, at the state education agency's Web site, which is generally linked to the governor's Web site. Once at the Medicaid Web site, look for information on the Medicaid State Plan. As this is a massive document, using a search function to find “special education” or “special education billing” will be useful. On the education agency Web site, information may be found on the Special Education page.

State Medicaid agencies generally offer training to the providers of Medicaid services. Ensure that your district is represented at such training. The best source of training is a workshop jointly offered by the state education and Medicaid agencies. In some cases, billing agents may offer training. Billing agents are for-profit entities who handle a great deal of the paperwork for the district, generally charging a percentage of revenue or a flat fee for the service. Whereas this can be quite valuable, the district should remember that billing agents are not Medicaid employees. If a situation arises in which the billing agent provides inaccurate information and the district makes billing errors, the district is liable for the errors rather than the billing agent.

Sometimes training targets administrative staff rather than the professionals who provide the services. It behooves speech-language pathologists (as well as physical therapists, occupational therapists, and nurses for whom the district may be billing Medicaid) to participate themselves in order to understand how the Medicaid requirements have an impact on their roles and responsibilities with respect to supervision and documentation. It is valuable to participate in such training as a team of professionals and administrators.

Another venue for training is state speech-language-hearing association conferences and workshops. State agency staff members are generally available for such meetings, if asked far enough in advance. Speech-language pathologists and administrators from districts that are successfully managing a Medicaid-billing program may also be valuable speakers.

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Meeting With District-Level Administrators

After acquiring a good understanding of the Medicaid program, speech-language pathologists should set up a meeting with the district-level administrator who is responsible for the Medicaid program, including adherence to Medicaid's requirements. The speech-language pathologist will want to address the qualification requirements for supervisor and supervisee, focusing first on the state Medicaid agency's requirements and then on ASHA's position (see the position statement and technical report, ASHA, 2004a and 2004b). The roles of supervisor and supervisee as found in this document should be discussed. Speech-language pathologists in the district may also request additional professional development in the supervisory process.

A key topic to be discussed is legal and liability issues. In addition to discussing the implications for the district of incorrectly meeting Medicaid requirements regarding the supervisor, the discussion should address the implications for an ASHA-certified speech-language pathologist for violation of the Code of Ethics. A frank discussion of the likelihood of losing one's certification (and possibly state license) for acting in a manner not in conformance with the Code of Ethics may assist district-level administrators in understanding the importance of supporting the speech-language pathologist. Advocacy should also address incentives for the speech-language pathologists for the extra work they will be doing to implement the Medicaid billing program. Although Medicaid has no requirement regarding the use of revenue generated from the billing program, speech-language pathologists should advocate that a portion of the revenue be used to support the speech-language program. Some revenue could be used to support the costs associated with the billing program (e.g., payment of ASHA certification and/or state licensure fees, payment for training and materials). Medicaid revenue could also be used for incentives that improve the working conditions (e.g., lowering caseloads, reducing the amount of travel, providing laptop computers for easier documentation, and purchasing additional clinical assessments, materials, and equipment). Other incentives may be financial, such as payment of a salary supplement or bonus to all speech-language pathologists who hold ASHA certification or additional allocations for conference attendance (e.g., ASHA, state convention).

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Frequently Asked Questions

  1. Why is the recommended amount of direct and indirect supervision the same for all levels of supervisees? I would think less experienced providers would require more supervision.

    The supervision levels described in the ASHA technical report are minimum levels of contact recommended. A supervisor must increase supervisory contacts as needed to “ensure that services are provided in a safe and effective manner in accordance with accepted standards of practice”.

  2. My district has been billing Medicaid for some time and is reluctant to develop the formal policies and procedures now recommended by ASHA. How can I convince them this is necessary?

    Share the ASHA documents with the district administration and offer to help draft policy guidelines. Use this opportunity to describe the benefits of supervision for Medicaid reimbursement as a means to improve services and enhance provider skills. Help the district administrator(s) understand the need for clearly written guidelines as a way to support quality services for students as well as to ensure compliance.

  3. What do I do if I see inappropriate services being provided by the non-Medicaid qualified personnel?

    Refer to the supervisor's roles and responsibilities established in your district for specific procedural guidelines. Perhaps the provider is in need of continuing education in a specific content area. Perhaps the provider needs to improve some aspect of clinical management skills. In any case, the area of need should be identified and an action plan developed with goals, supports needed, and a timeline for completion clearly described in order to bring the services to acceptable levels. In some cases, the supervisor may need to teach and model appropriate clinical methods.

    If your district has not developed roles and responsibilities for supervisors that address this issue, meet with the district administrator to discuss your concerns and request that such policies be developed.

  4. What do I do if we implement the above and the provider skills do not change?

    Refer to your district's procedural guidelines, which should include consequences for providers who do not meet established goals. If you feel the services provided were not safe, effective, and in accordance with accepted standards of practice, you should refuse to sign off on Medicaid billing. District guidelines should explain if and how information about the provider's lack of skill development can be used.

  5. My supervisee is using a different approach and/or techniques than I would have chosen for a student. Because the services are billed under my license, must the approach be consistent with one I would have used?

    The supervisor must determine that services are safe, effective, and in accordance with accepted standards of practice. If these criteria are met, the approach and techniques do not need to match those of the supervisor. In fact, this would be an opportunity for supervisor growth through exposure to new approaches and procedures.

  6. My supervisee is a very experienced and skilled clinician. The services he/she provides are excellent and I don't feel I can offer suggestions for improvement. Must I continue to supervise at the recommended levels?

    Yes, because the needs of a student or supervisee may change over time. The length of the direct supervision contacts may be brief but must be completed twice quarterly. Encourage the supervisee to identify aspects about his or her performance that he or she might wish to bring to a higher level of proficiency.

  7. My union will not permit me to do Medicaid supervision because I do not have a position recognized as supervisory in the union contract. What do I do?

    Meet with local union officials to explain the Medicaid billing requirements, detailing Medicaid's requirements for qualifications of persons who provide supervision. Explore vehicles that can be used to modify union criteria to ensure that Medicaid requirements can be met without having an adverse impact on union members' status within the union. If necessary, take the issue to state union officials.

  8. I am a state licensed and ASHA certified speech-language pathologist in a school district. I really do not want to be an “under the direction of” supervisor, nor do I want to “sign off” for noncertified staff. My principal/district administrator says that I am being insubordinate and will relieve me of my position. What do I do?

    Review your employment contract and consult with your union representatives, if unionized, regarding the terms and conditions of employment in your contract as it relates to the assignment of supervisory tasks. If your contract is “silent” on the issue, consider past precedent as it has occurred in your district. If you are in the same collective bargaining unit as the classroom teachers, compare your potential assignment and responsibilities in supervising a subordinate to the conditions applicable to a classroom teacher in supervising a classroom paraprofessional/aide or a student teacher. Is a classroom teacher asked if he or she would like to have a student teacher before the assignment is made? When a paraprofessional/aide is assigned to a classroom teacher's room, under what conditions does the paraprofessional work? For example, can the aide plan and provide academic instruction independently, or does the aide function under the direct, on-site supervision of the classroom teacher? If the latter, then there may be a discrepancy in the supervision of subordinates within the school district. Seek union representation to make the comparisons and argue disparate treatment under the contract.

  9. I am a state licensed and ASHA certified speech-language pathologist in a school district. My employer wants me to provide supervision solely for Medicaid reimbursement purposes to a colleague who does not have the required credentials for billing Medicaid yet who has been working as a speech-language pathologist for many years. Although my colleague's credentials satisfy state education agency requirements and have entitled him to function independently in a school setting, I know there are certain practices occurring that I would have difficulty condoning. I would feel trapped in a “catch-22” situation whereby I have no true supervisory authority regarding performance appraisal. What can I do to improve the situation?

    The purpose of supervision for Medicaid reimbursement is to ensure appropriate services for Medicaid-eligible students. The focus is not on the professional performance of a colleague per se. Notwithstanding, it is paradoxical to seemingly be able to ensure provision of services “in accordance with accepted standards of practice” without the inherent authority to evaluate the standards of practice demonstrated by the supervisee. This situation is compounded by the fact that legal liability for violations of Medicaid rules rests with the supervising speech-language pathologist and the school district, but not the supervisee. Further, it is the supervising speech-language pathologist who is burdened with additional ethical responsibilities. Therefore, it makes sense to negotiate for comprehensive supervisory authority with the title and salary increase to match. Keep in mind, however, that this may not only entail negotiations with school administration. It may also very well require the support of the collective bargaining unit to ensure conformity, or compatibility, with other unique positions—and stipends for same—contained in the employment contract.

  10. I have had concerns in the past regarding the accuracy of certain “legal” information regarding Medicaid rules and regulations that comes down through my school administration. If I have reason to question the legitimacy of information or of procedures I am expected to carry out, what can I do to feel more secure about the situation?

    When you have concerns regarding potential ramifications and/or consequences of your professional actions based on information given to you by your school district, you should seek clarification from additional sources. This document offers guidance on where to find Medicaid rules and regulations for your personal reading. Perhaps your state speech-language-hearing association has someone very well versed on the subject that you could contact. The ASHA National Office staff are available to assist with members' questions regarding all aspects of professional practice.

    Additionally, suggest to your district that a state Medicaid staff person come to your district to provide professional development to all providers responsible for billing and supervision. Another option is to request that your administration obtain a written legal opinion on an issue from the attorneys who are retained to represent the school district. Pose your questions and concerns in terms of preventing, or minimizing, legal and financial liability on the part of the school district. Procedures implemented in reliance upon the interpretations and recommendations of the district's own legal counsel should provide some protection. You are, of course, free to obtain a legal opinion privately.

    If no good faith discussion ensues with your employer that clarifies the issues, go back to your Code of Ethics. Does what you are being asked to do hold paramount the welfare of the client in accordance with the rules under Principle I of the Code? Do the services being provided by either you or the supervisee comport with accepted standards of practice in the spirit of Principle of Ethics II and as stipulated in its supporting Rules? Are the billing procedures you are being asked to implement (whether for your own services or for those “under the direction of” your supervision) legitimate, or do they suggest an appearance of impropriety, illegitimacy, or at its worst, fraudulent practice (see Principle of Ethics III, Rules A, C, D, and E)? Remember—ethics are personal. The obligation to uphold professional ethics cannot be relinquished or transferred to an employer or administrator. At some level you will need to determine when you cannot in good conscience comply with an employer's demand.

  11. What do I do if my district doesn't take the Medicaid requirements seriously?

    Remind your district of the Medicaid audits that have taken place around the country, some with requirements to “pay back” and all with negative publicity for the district.

  12. In an effort to protect student confidentiality, my district does not identify which students are Medicaid-eligible. Applying the recommended supervision guidelines to all the children on my supervisee's caseload is unrealistic. How do I resolve this?

    This issue should be addressed in written district policy. The district will need to develop a mechanism to identify Medicaid-eligible students requiring the necessary supervision or further adjust the supervisor's workload to accommodate recommended supervision time for all students on the supervisee's caseload.

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[1] Whenever the term services is used in this document, it refers to any speech-language pathology service (evaluation or intervention) covered by Medicaid, according to individual state plan requirements.

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Index terms: Medicaid, reimbursement, schools, supervision

Reference this material as: American Speech-Language-Hearing Association. (2005). Medicaid guidance for school-based speech-language pathology services: addressing the “under the direction of” rule [Guidelines]. Available from

© Copyright 2005 American Speech-Language-Hearing Association. All rights reserved.

Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.


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