Insurance Based vs Private Pay; And Why We Accept Both

When a parent starts to notice that their child’s oral functions are not progressing as quickly as their peers, it can naturally create anxiety and concern. Communication is one of the most important tools we have for connecting with the world and with others. When speech and language challenges arise, not only is their social growth jeopardized, a child’s ability to learn and grow in other areas are also affected. However, early and consistent therapy can make a meaningful difference to get and keep that child on track not only in communication but in their progress in every area of their growth. 

But paying for the therapy a loved one needs can be confusing and can cause even more anxiety for a family. Does speech therapy get covered by insurance? How does the process of using insurance benefits work? How much does speech therapy cost? What is private pay? Why do some speech therapy clinics only accept private pay? Why does inclusive accept insurance? What is private pay? Is private pay or insurance based therapy better? What is a super bill? We are here to answer all these questions and make sure your loved one gets the services they need while eliminating the financial stress. 

Most insurance plans cover speech therapy services as an existing medical benefit. This means you are already paying for speech therapy services through your insurance plan. If you are already paying for the services your child needs, then using insurance to cover services makes the most sense before turning to paying privately for services. A few conditions that will deem speech therapy necessary include: Speech sound disorders, Language delays, Autism spectrum disorder, Stuttering, Feeding or swallowing disorders, Neurological conditions affecting communication. Because these are medical or developmental conditions or delays that are deemed necessary by a licensed Speech Language professional, many insurance plans provide coverage with little out of pocket costs. 

Clinics that accept insurance help ensure that financial barriers do not stand in the way of communication development. By helping families utilize the benefits they already have, we are able to expand access to essential services and support better long-term outcomes.

As an Insurance-based speech therapy provider, we work directly with health insurance companies to help families use their existing medical benefits for therapy services. 

1. Initial Consultation - Either during our initial discussion to address concerns or during the patient’s evaluation we will collect the patient's health insurance information. 
2. Benefits Verification - Once the insurance information is collected by our team, we will then verify the patient’s benefits that cover Speech Therapy based on your specific insurance plan.
3. Evaluation - Before services begin, we will determine through a formal evaluation if Speech therapy intervention is needed and create a custom treatment plan to get your loved one back on track.
4. Ongoing Care and Billing - We then execute our speech plan! As we continue our ongoing care, our experienced billing team will submit all claims to insurance companies, follow up with any insurance hiccups, and follow detailed documentation requirements. For many families, this approach significantly reduces the out-of-pocket cost of therapy.

As a provider that accepts health insurance, it also requires us to provide the absolute best service for our patients. This is because insurance companies require us to maintain extensive clinical documentation, follow specific policy guidelines, coordinate with physicians when required, and manage claims submissions and follow-ups. These requirements are in force to make sure the best services and the therapy is provided to our patients. At the same time, since almost every individual has some form of health insurance, we are able to expand access to care for all families no matter what their financial situation looks like. No child should be left behind due to financial conditions. Every child should be given an opportunity to succeed. This starts with getting the children that need extra support the support they need to keep up with their peers and excel. 

Even though we accept insurance and follow these specific documentation guidelines to track progress, we are still able to provide the absolute best individualized therapy that fits the patients needs and learning style. We do this through: 

• evidence-based play-based learning, 
• change duration and frequency of sessions based on the patient's needs, 
• give follow up guidance and extra support to families, and 
• collaborate with families in the sessions to help educate parents and caregivers how to effectively practice speech and language development. 

None of this changes whether insurance is used to cover the cost or not!

Private Pay means that payment is due at the time of service. There are some clinics in the area that do not accept insurance and are private only. Why is this? Even as a health provider, navigating insurance is very tricky. To accept insurance as a health provider, a clinic first needs to get credentialed with that insurance company and become “in-network”. Once in-network, the clinic then needs to spend extra time, money, and resources to make sure insurance covers services, to document everything, to continuously follow up with and make sure claims are being submitted and accepted properly, and to follow their patient’s insurance's billing guidelines. Insurance reimbursement can also be slower causing a large delay in receiving payments for clinics that accept health insurance. Clinics that do not take health insurance do not believe that these extra services for their patients are worth their time, money, and resources. However, we believe that to provide the absolute best service for our patients we need to spend the extra time, money, and resources to reduce our patients financial burden and submit all claims on their behalf. Not all clinics are willing to submit claims to insurance companies on behalf of the patient, follow medical documentation requirements, nor help families access therapy through their existing health plan. But we are proud to say that we do! 

Below is a scenario to help better explain what out of pocket costs can look like. 

• An evaluation will cost about $250 out of pocket without insurance.
• A 30 minute speech therapy session will cost about $100-$150 per session without insurance. 
• If a treatment plan requires one 30 minute session per week; treatment will cost $100 x 52 weeks.
• This means that speech therapy will cost the patient around $5,200 for only 26 hours of therapy per year without insurance! For many families, this cost burden makes speech almost completely unattainable without insurance. 

While almost all of our patients utilize their health insurance to cover the cost of their speech therapy, there are some situations where private pay is necessary. This is why we accept both! 

The two most common scenarios where a patient may pay privately are below.  

1. Insurance Benefits are Exhausted - If all of their yearly insurance benefits for speech therapy from their individual plan have been exhausted. There are few insurance plans (not many) that will limit the number of speech therapy sessions per calendar year (for example, 20 sessions annually). In these cases, we first utilize all covered sessions and then transition to private pay if continued therapy is needed.
2. Services are Not Deemed Necessary - Sometimes a child is already meeting or exceeding developmental milestones, but a parent wants additional support for enrichment (“get ahead” or “stay ahead”). In these cases, insurance typically will not cover these sessions so private pay is required.

A superbill is a detailed receipt from a provider with medical codes that a patient can submit to their insurance company on their own through an out-of-network reimbursement. However, reimbursement is not guaranteed and can be very difficult and time consuming to submit without having prior experience submitting claims. Many insurance companies do not accept out of network reimbursement at all for speech therapy services causing the patient to be denied coverage all together. Because of these challenges, many families find it more reliable and less stressful to work with clinics that are in-network with insurance providers; like Inclusive! We don’t provide superbills to our patients because there is no need for us to. Here at Inclusive, we have in-network contracts with all of the insurance companies we accept insurance benefits from and we take care of all the insurance claims and billing for our patients!

Speech therapy can be life-changing, especially when started early and delivered consistently. While the financial side of care can feel overwhelming at first, understanding your options makes the process much more manageable. Using insurance benefits whenever possible is often the most practical and affordable path to get the speech services a loved one may need.

If you have questions about your coverage or where to begin, we’re here to help guide you every step of the way. Since every insurance plan is different, give us a call and we can walk you through your benefits!  If you are curious on which insurance companies we work with, please visit our billing page for more information.