Abby Barnes, M.S., CCC-SLP
Navigating health insurance can be tricky. That includes understanding when speech therapy is covered by insurance and when it isn’t. It can often take a lot of research and communication with your insurance company in order to fully understand your benefits.
However, there are several common reasons that speech therapy coverage gets denied. Let’s look at some of the top causes of insurance denials and what you can do to get speech therapy covered.
Denials related to authorization
In order to cover any medical service, your insurance may require authorization for that service. Healthcare.gov defines “authorization” as “a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.”
If authorization is required, speech therapy will not be covered without it. Let’s look at some reasons insurance may not give authorization.
1 There is not enough evidence of medical necessity
Let’s take an example of a parent seeking speech therapy for their child’s speech delay. If their pediatrician has not documented how the speech delay is medically affecting the child, insurance may not provide authorization.
What can you do? Contact your pediatrician to ask them to document the medical necessity. They may write that the speech delay is preventing the child from communicating their basic daily needs, or that they are unable to communicate in an emergency situation. These are both considered medical reasons someone may need speech therapy.
2 Your insurance doesn’t cover that specific treatment or condition
Some types of speech therapy treatments or conditions may not be covered by your insurance policy.
What can you do? Speak with your medical provider to see if there are other types of treatments covered by insurance that would be helpful. For example, perhaps the person needs speech services for articulation and stuttering, but stuttering is not covered by insurance. The client should request that services for articulation be addressed, so that they are able to get some type of speech therapy.
3 You’re moving from one medical facility with one speech therapy provider, to another facility with another speech therapy provider
Your insurance may deny authorization because you already have it from the first provider. So, a new authorization requested from the second facility would be denied.
What can you do? Ask the first provider to withdraw their authorization with your insurance company before you start speech therapy with a new provider.
4 The speech therapist is not in-network with the insurance company
Speech therapists must be credentialed with different insurances. Let’s say you use ABC Health insurance, but you go to see a speech therapist who isn’t credentialed with ABC Health. If ABC Health only covers speech therapy with in-network providers, any therapy done by this speech therapist would not be covered.
What can you do? You can keep this from happening by speaking with your insurance first. Identify whether the speech therapist is in-network with your insurance company before beginning services.
An important note: There are situations in which a speech therapist may be able to get authorization even if they’re out-of-network with your plan. That’s another reason it’s helpful to talk with your insurance company about your options.
Denials related to claims
A claim is a bill that is sent to your insurance company for a medical service you receive. It includes several standardized billing codes that summarize to the insurance company what took place. Here’s an example of what a claim includes:
Who? The patient’s name
What? A speech evaluation or therapy
Where? Virtually with Expressable
When? The date of the appointment
Why? The reason for needing speech therapy (diagnosis)
Below are some of the reasons an insurance company may deny a claim for speech therapy:
1 A non-covered service was provided and billed to insurance
For example, speech therapy for public speaking is not covered by insurance. If a claim for this service is sent to insurance, it would be denied.
What can you do? Talk to your insurance company ahead of time to understand if the desired service will be covered.
2 There is a missing referral from a doctor
Most speech therapy services require a written referral from a primary care doctor before therapy can begin.
What can you do? Discuss any speech concerns with your primary care doctor. Often doctors require their patients to be up-to-date with their wellness check before they will issue a referral for speech therapy.
3 A problem comes up because of multiple insurance policies
Some people have multiple insurance policies, such as a child with insurance through both parents’ employers, or someone with both a commercial and a Medicaid policy. There are rules about the order in which the insurance policies can be billed, called coordination of benefits. If the policies are billed out of order, the insurance company might deny the claim.
What can you do? When you give your insurance information to your speech therapy provider, it’s important to tell them about all insurance policies you have. They can help determine the order in which the policies should be billed to avoid any claim denials.
Your health insurance is there to help you get the services you need. But as you can see, insurance coverage can be complicated! The best way to avoid problems is to get as much information about your coverage as you can before starting speech therapy. Then, when you find your speech therapy provider, talk with their insurance team. They’ll do everything they can to ensure a smooth start to therapy for you.
How to pay for speech therapy without insurance
If you don’t have health insurance or decide not to use insurance, there are other ways to pay for speech therapy.
1 HSA or FSA
Speech therapy is often FSA eligible. That means if you have a flexible spending account (FSA) or health savings account (HSA), they will likely reimburse you for speech therapy services. This is something to ask your insurance company or employer about.
2 Out of pocket
Consider out-of-pocket payment for speech therapy. This is sometimes called “private pay.” It means paying for speech therapy yourself.
Although speech therapy is well worth the investment, out-of-pocket costs can get pricey. However, costs can differ from practice to practice, so it’s worth shopping around. This is one reason to look into online speech therapy. Virtual speech therapy often costs less than traditional in-person therapy, which has more overhead costs.
3 School speech therapy
If your child needs speech therapy, look into services offered at your public school. Your child may qualify for speech therapy at school.
One thing to note is that school speech therapy is often offered to kids as a group. Your child may not get the same one-on-one attention they would through a speech therapy practice. But group speech therapy is certainly better than no speech therapy at all, and school speech therapists work hard to give all their students the most time and attention possible.
