Episode 42 - Maximizing Therapy Assistants: Billing & Compliance in Florida

Aaron Marshall (00:24)
Hey everybody, welcome to this Spot Growth podcast. This is your host, Aaron Marshall with Extra Mile Billing. And today I'm just, really excited to bring back ⁓ one of our most beloved guests. ⁓ You guys love her, we love her, Dr. Debbie Campbell, ⁓ who runs a practice and is also just involved in so many aspects of

⁓ of SLP services here in the state of Florida and on so many committees and organizations. And she's just one of the best resources that we come to and especially for dealing with this question, which we just see so often. And you guys keep asking us, we want to keep revisiting it. We want to keep chewing on this and make sure that we're really getting a well-rounded answer to your questions about assistance, specifically.

SLPAs in the state of Florida. that's what we're going to be tackling here. Debbie, welcome back to the show. Thank you so much again for taking the time with us. ⁓ The first thing I really want to ask has to do with, ⁓ you know, kind of walking us through what assistance, specifically SLPAs, can and cannot do in the state of Florida. Can you help kind of walk us through that?

Debbie (01:26)
Bye.

Sure. So I want to start off by saying if you are a licensed practitioner in Florida, whether you're a speech pathologist or a speech language assistant, when you get that license, the state board requires, and you sign off on this, that you have to have read the state rules and the state statutes, i.e. laws, that relate to what you can and cannot do.

So what's really nice is when people ask me this question, I was like, well, if you go read the rules as part of your license, it actually very explicitly states what you can and cannot do. So for example, know, speech pathology assistants are absolutely able to treat speech and language disorders. They are able to write soap notes. They're able to give assessments, although they can't interpret them, but they can actually administer them. They even can do feeding and swallowing as long as...

They have been actively trained and have experience in doing it. Things that they can't do though is they can't of course do an initial evaluation. They also cannot misrepresent themselves as being a speech pathologist. And a big one that sometimes people don't realize is they're not allowed to sign any document unless it's been countersigned by a speech pathologist. So those are some of the real big takeaways that sometimes people are not aware of. But I always tell them like you don't have to guess.

because the state was pretty good about being very clear about the do's and don'ts and it's in writing form. So if you, you know, everybody as a speech pathologist this year, if you're a speech pathologist or speech assistant, your licenses are being renewed. So if there's ever a time for you to read those rules and statutes, now would be it because you're getting ready to sign that document again that says, I've read them. This is a good time for it.

Aaron Marshall (03:26)
Yeah. So talk me through the assessment and evaluation piece there because I think there is some nuance there. So when you say they're allowed to do assessments, but they're not allowed to do the initial evaluations, what about those re-evaluations? What part of the evaluation can they do and can they not?

Debbie (03:41)
Absolutely. So when you're doing an evaluation, obviously an initial evaluation needs and requires to be a speech language pathologist. So that's kind of a no-brainer. You've seen the kids coming in, know, adult client, you them for the first time, it must be a speech pathologist. When it comes to re-evaluations, in actuality, speech assistants take a big role in this. So for example, they can write the progress notes on a child.

So, you know, say they're working on past tense ED, they're allowed to write, you know, they were at 0 % producing past tense ED, now they're at 90 % at the word level, phrase level, via imitation. They're able to summarize that data. What they can't do is then interpret it. So the speech pathologist would then have to say, hmm, has that goal been met or do we need to continue it and advance it? So that's left up the interpretation part is left up to the speech pathologist. But also part of that reevaluation typically is testing.

And if a speech assistant has been trained how to give an assessment, they absolutely are able to administer it. Now, there's some little nuances of that. Let's give example of the clinical evaluation of language fundamentals or the self-test. In the self-test, for example, there is a section on there where it's a right or wrong answer, right? You ask them a question, it's word relationships, and they just give it back to you. Did they get the word relationship correct or incorrect? It's binary, right or wrong.

there are other sections of that test that might require interpretation, like sentence formation. So when they give you that sentence, if it is not cut and dry right or wrong, and you're like, I'm not sure how to grade this one, that does need to be left to the speech pathologist. But again, if they have read the manual, been trained by speech pathologists, have done on the job training and giving that assessment, they absolutely could administer the entire test. What's left ⁓ that they cannot do is A, any type of interpretation, whether within the test,

or with the test results. And the second thing is they can't write goals. So they can write progress notes. But if new goals need to be generated, those must be created by the speech pathologist, not the speech assistant. But if you think about, I think about like my reevaluations and sometimes they're pretty broad and what has to be accomplished for that reevaluation, we can probably give almost 80 % of that workload can go to the speech assistant.

They can get the current health information, background information, updated data. They're allowed to collect all of that information. So they save us a lot of time for reevaluations at our practice.

Aaron Marshall (06:04)
It really sounds like it. And I don't think that's something that, you know, that enough people are probably, you know, utilizing. mean, that's a, that, would be a huge help. mean, it's, it's almost like having an administrative assistant, you know, for your evaluation, which is such a big part of, know, of what you guys do every six months or, you know, on the

Debbie (06:20)
Absolutely. Yeah,

every, yeah, seriously. So every six months, I mean, so we have our speech assistants, they have assigned PlanoCare's there to work on. So they, you know, they get it all set up. They have the background information, new information the parent has provided. They've administered the assessment. They have scored the assessment for the binary information.

leaving it for the speech pathologist to finalize it. Then they write all the progress information. Then it gets turned over to the speech pathologist who does any interpretation. They edit it for anything they feel needs to be clarified or changed. And then they write the new goals and then the report's done. it really, I mean, they are such an integral part of a lot of people's practices when you can really understand the value that they bring to your practice.

Aaron Marshall (07:04)
That's awesome. ⁓ You also mentioned misrepresentation. Can you just explain that real quick? You don't want to misrepresent yourself.

Debbie (07:12)
Yes. So, you know, I joke about the fact, you I had a dad come in one day and he was like, hi, okay, let's go see the doctor. And I was like, hold up. So, you know, I'm a speech pathologist. So while I do have a PhD, like I am a speech pathologist, so I make sure that's very clear. My speech assistants are like, let's go see the speech pathologist. And they'll go, yes, I'm a speech assistant. So making very clear that our constituents are aware of what our role is and making sure they know whether you're a speech pathologist or speech assistant.

Some practices, how they accomplish this, people have name tags and it's clearly spelled out on that name tag what they are. But in practices where you're not doing that, we need to make sure that it's very clear what type of licensure these people have. Now the funny part is I joke about, I can have a master's level clinician with a year experience or I can have a speech assistant with 20 years experience and trust me, parents sometimes they are...

They're thinking my 20 year experience SLPA, they love them and they're they're rock stars, right? So that I understand master's degrees are important and they have a value to them, but these speech assistants that are highly trained and highly experienced, we don't worry about saying they're a speech assistant, because I know that parent knows they are just very gifted at what they do.

Aaron Marshall (08:28)
Yeah, yeah, no, that makes sense. and, know, oftentimes, I mean, people are making careers out of, know, being an SLPA or a CODA or a PTA. So, you know, it's just like anything else. mean, what do they say? 10,000 hours makes you an expert on, your particular career field. Yeah.

Debbie (08:36)
Yes. Yes.

Exactly.

Absolutely. And I even joke about I will get a graduate student and they'll have a question and I'll watch them walk over to my speech assistants and asking all kinds of questions. And to me that always speaks volumes of saying even our graduate students are recognizing the value and the talent in these speech assistants. Because like you said, these people, this is a career. This is a lifelong career for them. So they have truly honestly mastered this field.

Aaron Marshall (09:09)
Yeah, no, that makes sense. So another thing that I see come up quite a bit in the Facebook threads and questions that we see are related to the word direct supervision. So can you just explain what direct supervision is and what are the exceptions to direct supervision?

Debbie (09:22)
Yeah.

Okay,

I gotcha. ⁓ So I'm going to try not to go down too big of a rabbit hole. when this law was created back in, I to say 1996, at the time there was no training, right, for speech assistants. So what they did was they required that every single speech assistant required a speech pathologist to be on site. So direct supervision in statute is currently defined as on-site supervision, which means, and for the longest time it was like this,

If I was going to have a speech assistant work with me, I had to physically be in the building with them. I could not take the day off. ⁓ I couldn't go out to lunch. If they were working, I had to be on site. Well, then there was this little nuance of the statute that ⁓ back in 2017, where myself and Charlene Westman, who was the government ed person for Flascia, there was a little statement in there that said, unless acting under protocol. So what happened was we realized that there was a way that these seasoned, gifted speech assistants

would no longer have to be practicing with a speech pathologist on site. So what happened was a new rule was created and it actually has been around since 2020. And that rule means that if you have somebody who has not just demonstrated that they are competent at being a speech assistant, but they are truly proficient, then what they do is they fill out this form. It's called, ⁓ it's basically called a protocol form. ⁓ And what it is, it's an agreement between the speech assistant and the speech pathologist. And once that document has been signed and agreed upon,

that speech assistant can practice without an SLP in the building. Now there still has to be synchronous communication via phone call or Zoom, ⁓ anything that's synchronous, but that form has to be signed. So some mistakes that people have made is they're like, we heard that speech assistants don't need to be in the same building as a speech path. But what they didn't do is they didn't read the statutes and rules to realize there's a document that you have to have signed. And if you're having a speech assistant,

practicing without you being in the building and you do not have that form signed, you actually have violated licensure. So I tell people you are absolutely allowed that to happen, but you need to make sure that they're qualified, they're trained, and that document is signed in hand on and in their file. So you can prove that you approved that type of supervision. Otherwise they revert back to direct.

Aaron Marshall (11:49)
I got you. So just a quick clarification question about the protocols. So does this have to happen per patient or is this just per service provided? So, okay.

Debbie (12:01)
per service provider. So I

have a speech assistant who's under protocol once a year, she and I sit down and we fill this format. And it basically the objective of the form is to spell out what am I comfortable with her doing with me not being on site? And what am I only comfortable doing with being on site? So for example, if I have a speech assistant who's wanting to learn about feeding and swallowing, but they're not qualified to do it yet, I might have on that form, you can do articulation, you can do language, you can do AAC, but I will put off to the side. However,

Aaron Marshall (12:13)
Yep. Yep.

Debbie (12:30)
any feeding and swallowing still requires training. You cannot do that unless you have direct on-site supervision. So the forum is really awesome because you can actually say these are what you can do and these are what you can't. And so I've explained to different people what's really nice is you can have a transition period saying, all right, speech assistant, you can do maybe Arctic and language when I'm not in the building, but anything AAC, anything feeding, swallowing, anything voice, no, you require direct.

So it really gives us a nice way to allow people to gain more skills and then have more freedom without having to have that speechist pathologist in the building.

Aaron Marshall (13:06)
So as you're doing the evaluations of new patients or continuing patients, you're able to kind of categorize them into this, you know what, this patient can be seen by this SLPA. However, this patient, they're gonna require, you know, me or another SLP on site.

Debbie (13:19)
Yes. Yes,

exactly. So you could even do that. You could have a caseload where maybe two days a week, you don't have to be in the building with them because those are all clients that you have agreed upon and they're qualified with. Then you might say, OK, Wednesday, I'm going to be in the building with my speech assistant providing direct on-site supervision because that caseload for that day is not something where I'm comfortable not being in the building. Absolutely. You can create something like that. Yeah.

Aaron Marshall (13:43)
OK, no, that's great. That is ⁓ really super helpful. I'm going to throw a question at you here that just occurred to me because I've seen it a little bit, but it's not something that I think ⁓ I certainly didn't share with you ahead of time there. But the regulations talk about how many SLPAs that an SLP can supervise at a given time.

Debbie (14:10)
Yes.

Aaron Marshall (14:10)
And I believe it's, ⁓ was it two full-time or three part-time? Okay. So the part-time I think is where people get a little bit squirrely.

Debbie (14:13)
Two full time or three part time? Yep. Yes, yes.

Oh, darling. Listen,

listen, I 100 % agree with you. So let me tell you a couple of things. Flashev right now has already been in discussion about trying to align with ASHA. So ASHA actually has a higher SLP to SLPA ratio. I think it's three full time and maybe four or five part time. I do know that there is a plan, I think in the next year or two, where they are talking about revising the rules with the board and increasing that ratio.

Now in saying that the part-time is always up for question, right? Because who defines part-time? The problem with that is the board at one point told us, it's in writing, just go find it. Listen, I have read, if anybody's read Statutes and Rules, me. I can't find where it's defined. So the way that I tell people is, my company has a policy and procedure manual, and it defines full-time and part-time. So if my company is saying, if you work below 30 hours a week in your part-time,

then that is the guidance that we are using because I can't say you're part-time for my company, but you're full-time for the state. So I tell people, as long as you have a reason for how you determine part-time and ours isn't writing through our policy, that's how we just deem who is part-time and who's full-time. Here's a caveat to that. So the reason we want to change this is if I have one full-time person and one part-time person, I cannot add another person to my license because

once I add that one full-timer, I can only add one more person. So the only way you can have three part-time is everybody has to be part-time. So as soon as you add one full-time, that's it. Full-time, part-time doesn't matter for the second person. If we increase this ratio, what that's going to allow is I might be able to do two-fold and a part-time. So that's kind of the reason we're talking about the increase, not because we're wanting more speech pathology assistance to speech pathologists. It's that full-time, part-time that's caused problems.

because we can't mix and match the full and the part. That's where that came from.

Aaron Marshall (16:12)
Yeah, you're

entering into a different kind of gray area, which requires clarification. mean, there's so many pitfalls and trips and things like that. honestly, it's so good to have folks like you and Charlene, and who are just kind of pouring through this stuff and making sure that it's done fairly across the board and consistently with the rest of the country. So we appreciate it and thanks for taking that question. That's all.

Debbie (16:18)
Right. Yeah.

Yes.

No worries.

Yeah. ⁓

Aaron Marshall (16:40)
I learned something totally new there. ⁓

So I guess just to wrap us up here, what, you know, we see a lot of questions all the time about SLPAs and there seems to be a lot of fear. There seems to be a lot of hesitation, ⁓ just, you know, unknown when it comes, should I take on an SLPA? What's one big takeaway that you would have for clinic owners or supervisors? ⁓

Debbie (17:06)
I guess the big takeaway for me would be don't be afraid of speech assistants. Like, I get it scary in the beginning if you've never worked with a speech assistant before. For us, it's new. PTs and OTs, they've had CODAs and PTAs for years. And as I mentioned, like, they are valuable addition to us. So I tell speech pathologists, rip the bandaid off, try with one, have one speech assistant, train them, have them work right beside you, and it will absolutely open your mind up to the possibilities.

of this profession and the value that they can bring and the care that they give. Because I will tell you, I'm in awe of the progress that a lot of our kids make when they've worked with our speech assistants and thinking, holy cow, they have changed this kid's life. And it was a speech assistant who did it. And I don't mean that in a derogatory way, meaning like, you just proved my point of you add value, you are needed in this field. And I just wish more people would respect that and give them the opportunities.

because really they bring so much to our field. there's, know, our colleges are graduating of 300 undergrads, know, to 60 grads. There's a lot of people out there that have the potential to make this a career. We just need to be willing to give them those opportunities.

Aaron Marshall (18:19)
Yeah, and with such a deficit in services, just statewide and even countrywide, mean, we really do need as much help as we can get. And it can be a challenge at times, but it can also be such a huge benefit to the business.

Debbie (18:22)
off

Absolutely.

Yeah, risk reward man,

the reward way outweighs your time and effort that you spend getting these speech assistants trained. Once they're trained and up and running, they will bring more value to you than you could even imagine.

Aaron Marshall (18:45)
Well, okay, so last thing here, I just want to throw it over to you and say, is there anything that you're doing right now that you want to plug that you need help with that you'd like the rest of the community to ⁓ pitch in with?

Debbie (18:56)
A big one for us, so I'm a member of Flasha, a big member of Flasha. And what's frustrating to me is that a lot of people are like wanting change in Florida and wanting changes to happen in our profession. But the problem is you have to be part of an organization that's able to make those changes. And it's hard to do that when we have a little soft voice because we don't have enough members of Flasha. So my big thing I tell people is please join Flasha and make your voice heard and be part of this organization. As you mentioned,

I'm on conference calls in the evening. I've been on conference calls in the weekend. I've driven to Tallahassee. The whole reason we have this protocol rule for speech assistance, Charlene and I did it. We don't get paid for that. That was three years of our own time to do. But I value what I do and it was important. But we are limited in what we're capable of accomplishing because we don't have enough membership. And I really wish people would understand that we are working our tails off for you.

So give back to us and join and make our voices louder because the more members that we have, the more power that

Aaron Marshall (19:59)
That's great. And just to bounce off of that, mean, you guys know this raise that you got in Florida recently, that was a huge one, a 13 % raise across the board. That would not have been accomplished without Flasher. And they can do so much more. They can do so much more, but they've been fighting for you, but they certainly need your help and they certainly need your membership. So yeah, we're gonna...

Debbie (20:10)
Yep. I was on that committee. I was on that committee.

Aaron Marshall (20:28)
put a link in the description of the podcast so you can go click on that. Hey, pay for your whole office to ⁓ have memberships there, all your SLPs. You really need to get them involved because the more they have, the more good they can do. And we see a lot of good. So thank you, Debbie. I appreciate you. You're always an amazing guest. If there's anything else I can ever do to help you out, you just let me know.

Debbie (20:43)
Absolutely.

Well, thank you. Thank

you very much.

Aaron Marshall (20:57)
I appreciate it. And ⁓ yeah, thank you guys for listening.

Debbie (21:00)
Thank you.