Our SLP chat tonight, Monday, March 3, 2003 is being hosted by Barbara Samuels, M.A,
CCC-SLP.  Ms. Samuels will be leading us in a chat about Private Practice:Documentation
& Reimbursement Issues.  Barbara Samuels was Director and Supervisor of the Center for
Communication Disorders for 22 years.  This practice was staffed by up to six speech-
language pathologists, a dispensing audiologist and a four person office staff. The
practice served children and adults in acute hospitals, psychiatric hospitals, skilled
nursing facilities, patient homes and in their office.

Ms. Samuels has been a solo practitioner for the last seven years.  She is a former
President of The Academy of Private Practice in Speech Pathology and Audiology
(APPSPA) and The California Speech Pathologists and Audiologists in Private Practice. 
She is a Disability Evaluation Examiner for The Department of Social Services, a Peer
Reviewer for Policies and Procedures for The American Speech-Language-Hearing Association
(ASHA) and a Reviewer for The Medical Review Institute.  Ms. Samuels has made numerous
presentations to Speech-Language Pathologists about the subject of Private Practice.
Below the chat transcript you will find references that Ms. Samuels has provided.

<Robin> Welcome! Tonight we are chatting with Barbara Samuels, M.A, CCC/SLP, about Private
          Practice: Documentation & Reimbursement Issues.
<Robin> We have a good mix of SLP students and professionals here tonight.
<Robin> Glad you could all be here.
<Robin> Barbara, could you start with an overview of Private Practice?
<Barbara_Samuels> At this point, I will give you some guidelines for starting a private
<AdrienneFSU> Barbara, could you tell us your background?  How long have you
          been in private practice?
<Robin> Barbara Samuels was Director and Supervisor of the Center for Communication
          Disorders in California for 22 years.
<Barbara_Samuels> I had a staff for 22 years, now I am solo.  We treated all ages and
          most disabilities, did some accent reduction, etc.
<Krista> Did you deal with cognitive disabilities as one of the disabilities?
<Barbara_Samuels> Yes we dealt with cognitive disabilites.
<Barbara_Samuels> We recommend that you have at least five years experience before you go
          into private practice.
<dcjenkins> Why?
<Barbara Samuels> You need to really know what you are doing before you set out to do it
          on your own.  For one thing, when you start a private practice you are hungry for
          business and it is hard to turn away business.  So you need a good professional
<dcjenkins> That's a good reason.
<mvh> I think five years experience is necessary for a speech pathologist to really have a
          handle on sophisticated management of many disabilities, parental personalities,
          etc. etc.
<Barbara_Samuels> Along the way, you should pick up some business courses because while
          we are professionals first, if you want to run a private practice you need
          business know how.
<Barbara_Samuels> If you are going into private practice you should have at least a year's
          income in the bank to cover you.
<AdrienneFSU> What advice do you have for being a "boss"?
<Barbara_Samuels> To be a good boss, you need to know what you are doing.  I read
          everything my staff wrote, usually within a week of its writing, that meant all
          progress notes, monthly summaries, etc.
<AdrienneFSU> How did you handle differences of opinions as far as treatments, etc.?
<Barbara_Samuels> We discussed treatment problems at weekly staff meetings.  In general,
          if there was disagreement, I reserved the right to make decisions since I was
          paying the bill.
<AdrienneFSU> Did you have clients too?  It sounds like the supervisory/director jobs
          were keeping you busy!
<Barbara_Samuels> Yes, I always maintained some patients myself.  That was why I
          got into speech pathology.
<Nancy> I am a sole practitioner and am starting an agency which will serve early
          intervention and preschoolers.  Any advice about subcontracting to other SLP?
          There is a shortage of therapists here just outside NYC!
<Barbara_Samuels> Are you a direct provider or do you provide services for other agencies
          as a subcontractor?
<Nancy> Direct provider
<Barbara_Samuels> Hiring subcontractors or employees requires that you look into the
          person you are considering hiring.  You need to check references or you can
          potentially get in trouble.
<Nancy> How do you recommend finding good people with experience?
<Barbara_Samuels> I never really looked for people with experience.  I preferred to train
          them myself.  I took CFYs that I felt had the right attitude.
<mvh> I would think a better combo for creativity and success would be some CFYs and some
          experience...to train an already educated mind might prove to stifle creative
          therapy.  No?
<Barbara_Samuels> I preferred to hire CFY'S who knew they needed to learn rather than
          experienced clinicians whose approach to treatment might be different than mine.
          My entire staff worked from the same philosophical point of view.
<Nancy> Do you provide worker's comp to your subcontractors?
<Barbara_Samuels> When I had a staff, they were all employees, even though they were paid
          on the basis of hours of treatment per week, so I paid workers comp, malpractice
       insurance and all taxes.
<J.Shipes> I am a subcontractor because SLPs can not bill independently.
<Barbara_Samuels> You are right, and wrong.  An SLP can become a Medicare Certifed Rehab
          Agency.  I am one.  I also contract with other SLPs to allow them to do Medicare
          in their offices.
<J.Shipes> When you are subcontracting do not forget about the new HIPAA regulations.
<Barbara_Samuels> HIPAA regulations will affect everyone in our field.  Do you all know
          what HIPAA is?
<Krista> I don't.
<mvh> I don't.
<Barbara_Samuels> HIPAA is the Health Insurance Portability and Accountability
          Act.  Basically, it assures that no electronic information about a patient is
          posted without privacy being assured.
<Barbara_Samuels> If you are running a private practice you need to comply with the
          privacy regulations if you are using any electronic means except FAX.
<Nancy> Thanks
<Barbara_Samuels> That means that if you bill on line, you must meet the privacy regulations.
<Nancy> We can't bill for early intervention on line as far as I know.
<J.Shipes> We bill medicaid for early intervention.
<Nancy> We bill the county.
<Barbara_Samuels> I do not know about early intervnention.  I never dealt with it. 
          Electronic billing only means that you bill on line.  If you bill Medicaid you
          may be doing it on line.
<J.Shipes> Medicaid is billed online.
<stoneslp> How does an individual SLP become a Medicare certified agency?
<Barbara_Samuels> To become a Rehab agency you call your State Department of Health and
          they will send you the information.
<stoneslp> Thank you
<Nancy> It seems like setting up an agency is very state specific!
<Barbara_Samuels> No, setting up a Medicare agency is a national set up.  There are some
          minor differences by state.
<Robin> Barbara, lets talk about documentation and reimbursement issues.
<Barbara_Samuels> Reimbursement is a touchy issue.  Many of my colleagues no longer bill
          third parties.  Some do strictly private pay.  Some will provide the documentation
          for insurance.
<J.Shipes> It is difficult to get third parties to pay for SLP services for children
          because they expect the schools to take care of speech therapy.
<Barbara_Samuels> Insurance companies are notoriously bad about paying.  You need to be
          persistent.  Do not accept denials.
<Barbara_Samuels> Private schools do not provide services and may be willing to contract
          with you to provide the services.
<stoneslp> I work for agency that contracts for a school because they do not have enough
          SLPs, yet there is not enough extra work to warrant hiring a full-time SLP.
<dcjenkins> It seems easier to work with the patient directly for payment, is that true?
<Barbara_Samuels> It is much easier to work with the patient for direct pay if you can
          get it.
<Robin> Barbara, How do you handle reimbursement denials from insurance companies?
<Barbara_Samuels> To handle denials, you need to be very careful about documentation. 
          You need to show that the patient has a medical necessity for your services and
          that you are treating that problem.
<Barbara_Samuels> Your documentation is representative of you. You would not meet a
          client/patient looking dirty and poorly groomed.  The same is true of your
          documentation.  It is the only thing most payers will see of you. It needs to
          be clean, neat and precise.  It needs to show that the patient is making progress.
<AdrienneFSU> Is there anything specifically different you write in reports from Private
          Practice vs. reports written in hospitals, schools, etc?
<Barbara_Samuels> Documentation is slightly different depending upon the payment source
          but by and large, you are safe if you document every patient contact.  That way,
          if you get a denial, you have something to back up your charges.
<dcjenkins> Is that through soap notes?
<Barbara_Samuels> It can be SOAP but it does not need to be.
<GAL> What is SOAP?
<Robin> SOAP: subjective, objective, assessment, plan
<J.Shipes> It is my experience that part of coverage limitations insurance companies 
          state they do not pay for developmental disorders, only if it is directly related
          to an accident or illness.
<J.Shipes> I have had denials stating that they do not pay for codes in the 300 series.
<Barbara_Samuels> Insurance companies will try to avoid paying for anything.  If you can
          show that a patient was developing normally and then stopped, due to high fever,
          ear infections or an accident, you have a better chance of getting paid.
<Barbara_Samuels> Some insurance companies will pay for 300s and some will not.  If not,
          you need to find a diagnosis in the 700s that will work.
<J.Shipes> We do that most of the time they pay but some still do not.
<sue> Why not just bill the patient instead of their insurance company?
<J.Shipes> We eventually do, but after a denial from the insurance company a significant
          bill has accumulated.
<Barbara_Samuels> As long as you feel you were right in treating, go after the insurance
          company for payment.  Demand a peer review if necessary.
<J.Shipes> Do you continue treatment while you are trying to fight a denial?
<Barbara_Samuels> That depends on the case, how sure I am that the insurance company
          will eventually pay, based on review of the policy or what the insurance company
          told us up front and/or whether I feel that the family/patient will pay, if
          necessary.  I must admit that sometimes I continue because I know the patient
          needs it and at this stage in my career, I can afford to do some pro bono work.
<dcjenkins> What are the advantages of insurance company payment?  Is it more money?
<Barbara_Samuels>  The advantage of insurance payment is that many people can not afford
          to pay for tx privately.
<dcjenkins> I know it is hard for the patient to pay.
<dcjenkins> But I am thinking; it would be easier to contract with a Dr.'s office,
          hospital, etc.
<Barbara_Samuels> If you contract with a hospital, that is fine.  However, if you build
          them a good business they may decide to hire a staff person.
<dcjenkins> That's true
Barbara_Samuels> If you treat in a doctor's office, it is under the supervision of the MD
          and you loose you independence.
<dcjenkins> I guess I was thinking of them referring to you outside.
<GAL> If You assume you'll need 20 Sessions with a patient - Is it possible here to bill
          him in advance for most of the payment and then work freely???
<Barbara_Samuels> If you can get it, its fine.
<sue> Wouldn't it be easier to have the patient fight with the insurance company since
          they pay the premiums?
<Barbara_Samuels> Patients generally do not know what to say to the insurance company. 
          I have ghost written letters for patients and even for MDs to send to the
          insurance company.
<J.Shipes> Having the patient fight is the same as having your doctor ask you to file
          your own insurance yourself.  They do not understand the coding or why your
          techniques are skilled.
<Barbara_Samuels> That is very true.  The patient may know that you are helping but doesn't
          know how to state it.
<Barbara_Samuels> It is also because they do not know what their insurance is supposed
          to pay for services.  If you can get enough publicity and become known and
          successful, you can demand private pay.
<sue> Why should I hire someone or take EXTRA time to fight for a payment?  I'd rather
          do therapy with those who want it and are willing to pay something themselves!
<mvh> Parents should be asked to pay at least 30% up front...this is for their children's
          welfare and we are not the American Red Cross; we are educated, serious, capable
          professionals who should be expected to carry a cup for coins.
<GAL> Good...mvh...that's my point...
<mvh> GAL, Great!  The field needs more of us.  We agree to easily to work for free and
          it only hurts us and our patients in the long run.  Parents will pay more for
          soccer and ballet lessons than they will for speech pathology and that is because
          they charge up front.
<sue> Better to get some money than none.
<mvh> Sue, I am with you!
<GAL> THANK  YOU mvh ...I totally agree!
<J.Shipes> Sports and other "fun activities" sometimes show more "quick" benefits or
          progress and the children enjoy it more.  Unfortunately, their children improving
          in speech and language skills are not always a priority.
<mvh>   J Shipes that is scary...we need to educate the parents first in a free session
          and then treat their children in paid sessions and then any reimbursement they can
          get from their insurance company would go back into their pocket...good
          psychotherapists work this way.
<J.Shipes> We do, some parents do not feel like their child has a problem.  They are only
          there because their doctor told them to come.  They think the child will "out grow"
          the problem because their brother, cousin, or uncle did.
<J.Shipes> If you have a large practice solely on private pay that is great, however many
          people feel like they pay for insurance and therefore the insurance company should
          pay their parts.
<mvh> J.Shipes...you mystify me...parents would rather their children dance than think
          and speak?
<AdrienneFSU> mvh- it's similar to CVA patients that would rather go to PT to walk instead
          of SLP to organize thought, language, etc.
<dcjenkins> That's so true.
<J.Shipes> I work in a pediatric outpatient clinic and it is true.  I do not agree, but it
          is more common than you think.
<stoneslp> How do you decide which insurance to "accept" and/or how do you go about
          becoming a provider under a specific insurance company?
<Barbara_Samuels> You have to contact the insurance companies.  Some will allow you to
          enter their panels, some will not.  The most likely time to get into an insurance
          company is when you have one of their patients.
<dcjenkins> Wow.....good to know.
<Barbara_Samuels> As to which insurance companies to accept, you need to find out what
          they pay and when.  With many managed care companies there is a 45 business day
          wait to receive 30-50 % of reasonable and customary fees.
<stoneslp> Where would you go to learn names of HMOs- there are so many?
<Barbara_Samuels> I can not give you a list of insurance companies.  As you say, there are
          so many.  You should check the phone book in your area.
<Robin> Barbara, what is your policy about cancelled treatment sessions?
<Barbara_Samuels> My policy is that I can bill privately for any session cancelled in less
          than 24 hours.  I may or may not enforce it depending on the situation.
<mvh> When you begin to put your thoughts together on opening a private practice...do you
          need to specialize or can you initially branch out from the very beginning?
<Barbara_Samuels> You can begin with a general practice.  That is what I did.  When I
          started, we did SNF, HHA, hospital, then school contracts as well as office practice.
<mvh> Thank you.
<GAL> I'm interested to know from what source the patients might come to a NEWLY opened
          Private Practice?
<Barbara_Samuels> That is one of the reasons for having experience.  Then the doctors and
          others know you and will refer patients.
<J.Shipes> You should introduce yourself to the physicians in your area-let them know what
          you do and the services you provide.
<Barbara_Samuels> Absolutely.  We always sent a letter and report to the doctor after an
          eval and every month thereafter until the DC.  That keeps you name in their minds.
<J.Shipes> I go to the Doctor's office at least quarterly and speak to them personally when
          they are available to keep a face to a name.
<GAL> Since I was working In Israel for 15 years as a Private Practioner...and my main
          interest was voice & stuttering therapy, who might refer singers or actors for
          treatment here???
<Robin> ENTs
<GAL> Thank  You - What about Actors'-schools???
<Robin> Another good source....maybe voice teachers.
<Barbara_Samuels> Word of mouth is also a very good source.  If you belong to a special
          interest section you may get referrals there.
<GAL> What about publicity??? Is it free??? How would you suggest doing it?
<Robin><GAL>...May is Better Speech and Hearing month...it is a good time to do some
<GAL> How would you suggest doing that???
<Robin> ASHA usually has some information about this on their website.
<Barbara_Samuels> As to publicity, there is no limit as long as you do not promise a cure.  You can contact a local newspaper and offer to write a column, or a local radio station.
<Barbara_Samuels> Better Speech and Hearing month offers an opportunity to do free
          screening as well as writing for information wherever you can.
<Robin> Free screenings is a good idea....I have helped private practitioners do that in
          many private schools.
<stoneslp> That's a great idea- especially at preschools.
<Barbara_Samuels> If you are in a small community, you may even be able to do a public
          service announcement.
<Barbara_Samuels> You can visit doctors offices and leave information.  You will need to
          do it many times to become known.
<Barbara_Samuels> You can set up a free screening in a community mall to attract a wider
          potential patient load.
<GAL> How about publicity using Fax? URL? Internet?
<Barbara_Samuels> Many members of the Academy of Private Practice in Speech Pathology and
          Audiology have web sites and feel they are useful.
<Robin> We have been chatting for nearly an hour.....are there any more questions for
<dcjenkins> Barbara, how much time do you spend on paperwork each day?
<mvh> Yes, how much time do you spend on paperwork...seems to outweigh time for treatment.
<Barbara_Samuels> I would guess that on average now, I spend about an hour a day on
          paperwork.  I have someone who comes in to do my billing and transcribe my
          dictation.  At this point, I am semi-retired and only spend about 10 hours a week
          in tx.
<dcjenkins> ok
<GAL> Do you charge patients differently as to their problem???
<stoneslp> Unless you are utilizing additional tools (ie MBS) it does not sound ethical
          to change rate according to diagnosis for a private pay.
<Barbara_Samuels> No, I do not charge differently based on the problem.  I have some
          longstanding patients I do not charge as much as the new ones who came in later.
<J.Shipes> There are codes called ICD-9 codes and CPT codes you use to bill.  This will
          change according to the procedure and diagnosis.
<GAL> Thanks
<Barbara_Samuels> Basically, the only CPT codes we can use are 92506 for DX and 92507
          for TX.  There are special codes for swallowing, etc. but I bill the same.
<dcjenkins> J.Shipes, do you work in a hospital or clinic or private practice?
<J.Shipes> I work in all of them.  I am a private contractor and contract with pediatric
          outpatient clinics, hospitals and nursing homes.
<dcjenkins> ok
<Robin> Barbara, thank you so much for sharing your expertise about private practice
          with us!
<stoneslp> Yes, thank you!
<GAL> Thank you, I learned a lot from you all !!!
<J.Shipes> Thank you
<dcjenkins> Thanks Barbara
<Barbara_Samuels> You are welcome.  It has been my pleasure.
<Barbara_Samuels> Everyone is welcome to attend The Academy of Private Practice in Speech
          Pathology and Audiology Spring Conference and Institute May 1-3, 2003 in Toronto,
          Ontario, Canada.  For more information visit www.aappspa.org.
<Robin> Thank you to all of you who have joined us tonight.
<AdrienneFSU> Thanks for all the great questions!
<Barbara_Samuels> Good luck to all of you.  You represent our future.


AVAILABLE FROM ASHA.  Barbara Samuels and several other members of APPSPA have
contributed chapters to this book.




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