Speech Therapy: Identifying signals and trends for potential FWA (Fraud, Waste, and Abuse)
Speech Language Pathology serves as a pathway for many individuals, unlocking the gates to communication. With the expected rise in labor and increased awareness of speech and language disorders, Program Integrity and SIU teams should be aware of potential signals or areas of interest within this space.
According to the Bureau of Labor Statistics, Speech-Language Pathologists are projected to grow much faster than the average of all occupations. As the baby-boom population grows older, there will be more instances of health conditions such as strokes and dementia that could cause speech and language impairments. Additionally, increased awareness of speech and language disorders should lead to a need for more speech-language pathologists for younger age groups.
Speech-Language Pathologists work with people of all ages and treat many types of communication problems. These include problems with speech sounds, language, literacy, voice, fluency, and feeding/swallowing. Some speech-language pathologists specialize in working with specific age groups, such as children or older adults. The American Speech Language Hearing Association National Data Reports identifies two populations (Adult & Pre-Kindergarten) due to the different treatment models. Toward that end, the differences between these age groups are covered accordingly.
Pre-Kindergarten:
According to the American Speech-Language Hearing Association’s National Outcomes Measurement System for Pre-Kindergarten National Data Report (2018-2022), several of the data aspects focused on various areas such as demographics, therapy settings, service delivery models, service delivery settings, therapy duration and frequency, and outcomes. These results provide important benchmarks for evaluating the effectiveness of speech therapy interventions and guiding efforts to optimize service delivery and outcomes for pre-kindergarten children.
Reviewing these reports can help stakeholders understand current practices with an avenue to identify areas of interest for claims data analysis. For Pre-Kindergarten patients, most patients received one (1) therapy session per week. More specifically, the typical length of a session was between 21-31 minutes.
What should your health plan consider as outlier utilization or unlikely services for children?
- Providers representing excessive frequency and duration
- Cumulative Site of Services analysis (Home, School, Office, etc…)
- Presumed hours by date of service compared to business practice modeling
- Potential service overlaps by beneficiary and date of treatment
What should your health plan consider as outlier utilization or unlikely services for adults?
Adult speech therapy treatment contrasts children in an outpatient setting. In most cases, patients received two (2) therapy sessions per week for 46-60 minutes per session.
In the adult population, speech therapy restores speech after a stroke, traumatic brain injury, accident, or other surgical/medical conditions.
There can be distinct aspects when reviewing speech-language services rendered to adults that include:
- Non-covered diagnoses after the acute phase of a CVA or Stroke
- Services billed within an inpatient setting
- Exceeding benefits beyond the treatment period
What procedure codes would a speech therapy provider submit for payment?
The table below includes, but is not limited to, typical services pertaining to speech therapy and can be used for general utilization comparison by peer groups with Codoxo’s AI detection categories and/or Query Aggregates tool.
| CPT and HCPCS Codes | Code Description |
|---|---|
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual |
| 92508 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals |
| 92521 | Evaluation of speech fluency (eg, stuttering, cluttering) |
| 92522 | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria |
| 92523 | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) |
| 92524 | Behavioral and qualitative analysis of voice and resonance |
| 92526 | Treatment of swallowing dysfunction and/or oral function for feeding |
| G0153 | Services performed by a qualified speech and language pathologist in the home health or hospice setting, each 15 minutes |
| G0161 | Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes |
| S9128 | Speech therapy, in the home, per diem |
| S9152 | Speech therapy, re-evaluation |
How can Fraud Scope assist your health plan or agency with identifying potential FWA for speech therapy services?
Recently, Fraud Scope identified a speech therapy provider with clear outlier utilization compared to the peer group. When our partner health plan opened an investigation and reviewed medical records, they identified numerous issues, such as unlicensed and non-credentialed providers, and improper documentation. While the medical records provided evidence of improper practices and inappropriate billing, the peer group comparison and AI detectors provided the initial signal to review the provider.
While reviewing a peer group systemically, Fraud Scope’s AI detection and rules-based categories, such as Frequent Combinations, Physician Time, Multiple Claims, Time Behavior, Suspicious Trends, and MUE Violations, can assist health plans and agencies with identifying providers with outlier utilization and direct billing violations. When reviewing an individual provider, Fraud Scope offers Provider Codes and Query Aggregates as summary analysis tools that quickly identify areas of interest like volumes by claim composition, paid per patient, and other summaries in utilization compared to their peer group.
References:
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Speech-Language Pathologists
https://www.bls.gov/ooh/healthcare/speech-language-pathologists.htm
American Speech-Language-Hearing Association. (2023). National Outcomes Measurement System (NOMS)
https://www.asha.org/noms/noms-data-reports/
Pre-Kindergarten National Data Report 2023.
https://www.asha.org/siteassets/noms/pre-kindergarten-noms-data-report.pdf
Adults in Healthcare–Outpatient National Data Report 2023. https://www.asha.org/siteassets/noms/adult-noms-outpatient-data-report.pdf
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