So You Want Full Auth

Most evaluating speech therapists are familiar with the struggle to obtain authorization for their clients. Personally, I operate in home-health, and deal with Medicaid only. As is widely known, different providers operate under different guidelines for authorizing speech therapy services which continually change. Some of the trends that I have noted as a therapist include:

- Minimal to no authorization for stuttering therapy;

- Denial of clients with standard scores lower than 75;

- Denial of clients whose scores appear to "regress", although they have celebrated a birthday since their last re-auth and now fall into a new bracket of standard scoring;

- Partial auth approval with high emphasis on implementation and documentation of a Home Exercise Program (HEP); and/or

- Partial auth approval (1-3 months) with request to re-evaluate with the same standardized test.

This can be frustrating as a therapist, especially when you have a client who performs well on formalized items but falls apart in carryover or whose true areas of deficit are difficult to test formally. 

While I still am forced to deal with my own share of partial auth's and denials, there are a few things I am careful to include on all evaluations in attempt to win at this game we call "authorization."

1) Magic Words:

"Medically necessary."

"Spontaneous recovery is not likely based upon..."

"Implementation of a HEP."

"Cannot communicate wants and needs in a age-appropriate manner."

If you want to get the attention of providers, you have to speak their language. Make sure to include key terms in your summaries that readers look for when approving evaluations. I like to especially note that a child's errors are NON-developmental and therefore spontaneous recovery is unlikely, as many people still hold to the "they'll grow out of it" theory, especially when standard scores walk the line around low average to moderate. 

"Medically necessary" is a funny term. You can mention that in relation to a formal medical diagnosis or towards aspect of their deficits that is more specialized and requires formalized instruction, such as apraxia or hearing loss. 

For children under 3, you might need to highlight why Early Childhood Intervention may not be preferable to private or home-health services, if you are operating under that sphere. I like to note the difference in frequency of services between the two settings and whether or not the parent is specifically requesting home-health or private services.

2) Highlight informal implications of the child's deficits, such as an inability to communicate on an age-appropriate level with peers or safety implications.

Personal safety is always a good argument towards working towards communication skills.

3) Mention whether this will likely be the last period of authorization requested for the child, based on expected progress. 

This is obviously not possible for every child, but for children who I have had on caseload for a while and/or plan to discharge, I might note this if appropriate.

4) Include informal speech samples whenever necessary.

Seems obvious, but taking a short, paragraph-length speech sample can bring out aspects of the child's speech that was not noted through formal items. Personally, I have a child that struggles with word-finding on common vocabulary at times. Informal speech samples can bring these types of errors to light.

5) If standard scores are near or above 75, consider re-testing with a less sensitive yet appropriate test.

For example, the GFTA-2 is often too sensitive for my little guys 4 and under. If they score below 75, I will often follow up with the CAAP. For the PLS, the CASL or CELF can be a good follow-up since it uses subtests. 

And there you have it! Some of my favorite authorization tips and tricks. 

Let me know in the comments what you've found works for you!