Funding a Speech Generating Device (SGD): 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:
- 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.
- 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.
- 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.
Exclusive Preferred Provider Arrangements
Preferred provider arrangements are agreements between insurance companies or other third party funding agents and manufacturers or suppliers of durable medical equipment (DME). AAC devices are classified as DME. The advantage of such arrangements to funding agents is that they can negotiate a lower price for providing AAC devices. The incentive to participate in these arrangements for manufacturers and suppliers is that their products will be covered and they may be given an exclusive providership. When this exclusive providership happens, AAC consumers can be hurt.
The way things work from the consumer and service provider perspective is this. A comprehensive assessment is completed. A recommendation is made for an AAC system (device, language application program, peripherals, etc.) that will result in the highest communication performance and best life experience. The request is made for funding. When preferred provider arrangements are in place, the funding agent may reply with a denial for the selected the AAC system OR replies with the intention of providing an AAC system other than the one selected in the AAC assessment.
The appropriate response from both the AAC team and the family is to advocate for the selected system. This means that the funding agent must be contacted immediately with the message that the selected system cannot be changed. This may mean following through with an appeal process. However, the funding agent can be directed to components of the comprehensive assessment report that support the selected system. The following points may be helpful:
- Point out that professionals follow a Code of Ethics and basing AAC recommendations on funding policies violates professional obligations.
- Point out the a comprehensive AAC assessment must present the full range of AAC options, that the principles of evidence-based practice were followed, and that the client/family was fully informed when making a decisions on the specific AAC system selected for funding.
- Point out features that are distinctive with the selected system.
- Point out the performance (clinical data) that was achieved during the trial of the selected system and used to determine the intervention that would most likely result in optimized communication.
- Point out the user and family preferences and satisfaction with the selected system.
- Point out that the AAC system from this preferred provided was specifically rejected give the reasons.
The experience of AAC teams and families who have challenged exclusive or preferred provider arrangements has been positive. The goal of AAC as expressed by the American Speech-Language-Hearing Association (ASHA) is to optimize communication. Anything less is not acceptable to individuals who rely on AAC and families. Anything less should not be acceptable to AAC team members holding paramount the interests of individuals who cannot speak.
Contact us if you need help with this process. If you have experience with this funding problem, please consider sharing your testimonial with us as we build evidence to stop this practice. Do not allow funding agents to override comprehensive AAC assessments and in the process reduce the communication performance and life experience of individuals who use AAC.