Note: This post is written from an SLP point-of-view, but it’ll work for OTs and PTs too!
Prior authorizations have rapidly become the norm. That means that if you can’t show a need for skilled services, the insurer won’t pay for treatment.
Even the most Type A of pediatric SLPs don’t get excited about tedious paperwork. We go into speech therapy because we want to help our kiddos, not so that we can spend hours on documentation!
But good documentation is important if you want payers to approve treatment and pay claims. The less you have to go back and forth with payers, the more time you’ll have for more important things.
In a webinar she did for ASHA, Shannon Butkus, MS, CCC-SLP laid out three easy-to-follow rules that will help you demonstrate the medical necessity of treatment.
Here are the rules according to Butkus[1]:
- describe how the disorder impairs the patient’s functional status
- establish goals that focus on achieving function
- lay out discharge criteria with an end goal in mind
Let’s dig a little deeper to see how you can implement these rules to increase your prior authorization approval rates.
Butkus’ clinic has a 98% acceptance rate! Her clinic has doubled the time they spend on initial evals, and their reports are getting longer.
So unfortunately, one of the primary ways to increase your acceptance rate is to spend more time on your reports.
I know spending more time on documentation is the last thing you want to do, but trust me! It’ll pay off in the long run. (And I’ve included a free download at the end of this post to help you document more efficiently and effectively.)
The Framework
Here are three questions you can use as a framework to make sure you’re including all the information payers will want to see. By answering these questions, you’ll know you’re covering each of Butkus’ recommendations.
1. How does the disorder affect your patient’s functional status?
First, you need to describe how the disorder affects functional communication and safety.
Another way to think about it is:
“How will the treatment save the payer money?”
How will getting treatment now reduce costs in the future? For instance, will your kiddo require less support staff as a result of the treatment? Will the treatment keep them safe and help them avoid an accident that would require future intervention?
2. What are your goals and how will they lead to improved functional outcomes?
Next, you should develop SMART goals that are focused on functional outcomes.
The International Classification of Functioning, Disability, and Health (ICF) is “stated as the framework for the field in both the Scope of Practice for Speech-Language Pathology (2001) and the Scope of Practice for Audiology (2004)”[2]. It was developed by the World Health Organization, and it emphasizes function.
So keep the ICF framework in mind, and download the SLP Documentation Kit at the bottom of this post for a handout that will help you create SMART goals focused on functional outcomes.
3. How will you know that treatment is complete?
Finally, include specific discharge criteria.
Insurers expect us to have an end in mind. As Butkus says, “therapy is not life-long” and “[a]lthough we don’t have a crystal ball, we should be able to identify criteria for discharge.”[1]
So provide the specific end goal (or goals) and the criteria that will let you will know when the patient has reached that point.
SLP Documentation Kit
It may take some time to adjust to this new framework, and it will probably make your reports longer (it did for Butkus), but you’ll be repaid for that time by reducing the constant back and forth with payers.
You can also save time by finding ways to document more efficiently. To increase your documentation efficiency, download our SLP documentation kit below. It includes some handouts and a SOAP Note Template that should reduce the time you spend on documentation, so that you have more time to include the information that payers want to see.
[1] Butkus, S. (2018, March). Documentation Essentials for Pediatric SLPs: Articulating the Need for Skilled Services Notes. Notes from an on-demand webinar presented for ASHA members.
[2] ASHA (2018, April). International Classification of Functioning, Disability, and Health (ICF). Explanation of ICF from ASHA’s website.