School and Community Based Therapy Services: Understanding Your Options and Avoiding Insurance Denials

School and Community Based Therapy Services: Understanding Your Options and Avoiding Insurance Denials

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Occupational therapy (OT), physical therapy (PT) and speech-language pathology (SLP) services are necessary for many children with disabilities. This fact sheet explains the differences between therapies received at school and in the community, and how to ensure the cost of these therapies is covered.

Therapists and Families Working Together

Children get the most benefit from therapy services when families and therapists work together to agree on what is needed. Options include therapy only at school, only in a clinic or other community setting, or a combination of both. A therapy plan, with clear goals, needs to be developed with family input to decide the type, amount and location of therapy services that are most helpful for a child.

Provider Communication                                                                                                                                           

School and community therapists working together are essential to coordinate a child’s therapy. This coordination helps to prevent duplication of services (working toward the same therapy goals in more than one setting). Any duplication may result in your child’s insurance or Wisconsin Medicaid denying payment for therapy services. Communication between therapists is the best way to reduce the chances of duplication. Your child’s therapists can communicate by phone, email, written logs or at the Individualized Education Plan (IEP) meeting to craft different goals for the therapy plan.

Therapy Goals

The goal of community-based services should be to improve a child’s ability to function and increase independence at home and in the community. The goal of school-based services is to maintain or improve a child’s education.

Avoiding Duplication of Services                                                                                                                                     

School and community-based services goals must be different. A child may need therapy services to take part in school, but not in the community (or the other way around). So, therapy goals must be written to be  specific: schools must show their goals are educationally necessary, while community-based therapy goals need to be medically necessary.

Families are responsible for making sure their insurance plan, HMO or their child’s Medicaid card covers the cost of community-based therapy and school is responsible for educational therapy. Medicaid will not pay for a community therapy service that is provided, or should be provided, at school. This is a good check on your school system because schools often bill Medicaid for the services they provide. In this case, the purpose of having a clinic or other community-based therapists complete a prior authorization (PA)* request is to explain how their therapy goals are different from the school’s.

It’s also a good idea to carefully review your child’s IEP to make sure there isn’t any duplication with community-based therapy. Medicaid typically checks for duplication by requesting a copy of your child’s IEP when a clinic or community-based provider submits a prior authorization request for services.

*Wisconsin’s Department of Health Services recently simplified the Medicaid PA process to increase access to community therapy services. Information can be found at ForwardHealth Updates 2018-03 and 2019-14.

Understanding each type of therapy and how they can work together will guide families and therapists as they plan for the most helpful services for a child.

School-Based Therapy

School-based therapy must follow federal and state laws. Therapy at school  is considered a related service to special education and is provided only if the child needs therapy to be able to function in the educational setting.

  • The need for school therapy is decided by the IEP team with parents as equal members. The team decides when, where, how often and the length of therapy sessions.
  • Therapy is provided at school and can be done in classrooms, hallways, gyms, playgrounds, lunchrooms, bathrooms or in separate therapy  space.
  • Therapy may be provided one-on-one, in small groups or in the classroom by a therapist or therapy assistant. Intervention may or may not be provided directly with the child. Working with school staff to modify the child’s environment and daily school activities is part of school therapy.
  • The decision to end therapy services is made by the IEP team. It may happen because a student is no longer is eligible for special education, other members of the IEP team can provide the services, or when the child can perform school tasks independently.
    • There may still be a need for community-based services after school-based therapy has ended.

Community-Based Therapy Services:  Therapies provided at a clinic, hospital, in the home or other setting outside of school.

Community-Based Therapy

Community-based therapy must follow state and national practice guidelines that focus on a child’s medical and functional needs in home and community settings.

  • In community-based therapy the provider, family and therapist(s) make the decision about the amount of therapy. For example, weekly visits for 45-minute sessions. The amount of therapy actually received may be different because the insurance plan, Medicaid or other funding sources won’t reimburse for the recommended services. Payment denials are often based on a perceived duplication of service between community and school providers.
  • A therapist or therapist assistant usually provides individual treatment. They might assign activities to work on at home (home program). The therapist will also provide ongoing caregiver training to help the child continue to practice therapy between community-based appointments.
  • Families can seek out services from a therapist who has specialty training, like soft-tissue stabilization or sensory integration.
  • Treatment may stop for many reasons, like functional skills have been reached, the child is stable with the therapy program, no additional progress will likely be made, or a family asks to be discharged.
    • There may still be a need for school-based therapy after community-based therapy has ended.

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