CMS’s recent reversal of its interpretation of Clinical Fellows (CFs) should have no effect on the pending resolution for the following reasons:

1. The reversal is contingent on speech-language pathologists meeting their state licensure requirements. Thus, the CMS reversal explicitly leaves it up to the State of Virginia to decide on the criteria for who receives a full, unconditional license in our state, and who can therefore treat Medicare patients.

2. The CMS reversal does not address the questions front and center in our industry….why is there a CF requirement process in place for speech-language pathology graduates who have passed the Praxis exam, and is this process still relevant in today’s various practice settings.

Here is the issue in a nutshell: 

In its own words, ASHA has said this about CFs: “The scope of practice (evaluation, diagnosis, treatment) for CFs and SLPs is the same whether an individual holds a provisional or a full license……Therefore, the varied licensure title is largely a distinction without difference….”

Thus, we have to ask the question if a CF (Provisional License) and someone with their CCCs (Full License) in the State of Virginia all can do the same things as practitioners, why don’t they have the same license??? The answer is that they should. 

Pro CF provisional license advocates claim that SLP graduates need more clinical hours to augment their training. However, the current CF process as outlined by ASHA only requires one hour a week (a total of 36 hours over nine months) of supervision, with only 30 minutes per week (a total of 18 hours over 9 months) requiring actual observation of therapy. Up to 6 hours can be completed in one day, with some CFs going months without seeing or hearing from their CF supervisor. Simply put, 36 hours over nine months is not worth the administrative burden involved and has minimal impact on the new graduate’s development. 

We can all speculate about the reasons why ASHA and other legacy advocates are holding onto this outdated model, but the bottom line is that the ones who suffer are the patients who can’t receive timely care.

Here are the facts:

• Virginia is currently ranked 42 in the country in the ratio of SLPs to 100,000 residents. This means that citizens are going without or receiving delayed care. I encourage the board to do a simple survey of children’s hospitals and private practices in our state. They will find there are up to 400-500 children on a waitlist at some facilities. We desperately need more SLPs with full, unconditional licenses.

• SHAV is on record as supporting the proposed resolution.

• Many insurance companies will not reimburse for services performed by CFs.

Here is a note from ASHA itself: “Please note. Some private payers and state Medicaid programs do not recognize provisional licensure as meeting their personnel standards for billing purposes. ASHA members should always verify billing and supervision requirements with each payer individually.” I can’t think of any other national medical organization with such a disclaimer about a class of professionals.

For Virginia, and our large military population, TRICARE does not allow CFs to see active military members or their beneficiaries, thus these patients can only be seen by those with their CCCs. This has a huge impact on our day-to-day operation with the Norfolk Naval Base being the largest in our country along with numerous other military institutions in our area and state.

Virginia Medicaid considers CFs to be “assistants”, and the supervision requirements are much stricter than the state code. This means that if a CF has 50 Medicaid patients on their caseload, I have to pay a CF SUPERVISOR to jointly see each patient with the CF once a month. Thus, I am paying two therapists to do one job……our margins are small, and reimbursements are decreasing. This makes no sense, but we have to comply with Medicaid’s rules.

• The administrative and clinical burdens are overwhelming for any therapy company trying to do things the right way and follow the rules. In my above example, the CF SUPERVISOR could be seeing an extra 50 patients a month, but can’t because they have to shadow the CF’s Medicaid patients.

• When a physical or occupational therapist graduates and passes the necessary examinations, they receive full, unconditional licenses. Speech-language pathologists should do the same. There is no logical financial, clinical, or administrative reason to make SLPs go through more steps for full licensure.

Here are some other myths that I have read from opposition to the resolution:

• Myth #1.  Public Safety??? By state code, CFs can do whatever a fully licensed SLP can do. As ASHA said, “licensure title is largely a distinction without difference.” Public safety is not a relevant issue here.

• Myth #2.  The CF is a structured/mentored experience. I have to disagree. While not true at our clinics, CF Supervisors are often in separate physical buildings than the CFs they are overseeing. There is no audit or checking regarding hours submitted or progress made by any national association. Supervision in most settings is minimal, and most folks are just going through the motion for nine months to check the box to get their CCCs.

• Myth #3.  The resolution would increase administrative burden on the state board. The board does a tremendous job, and this would actually decrease the board’s tasks by only having to issue licensure one time, not two. Presently, the board is issuing both provisional licenses and six/nine months later, full licenses. The process would go from two steps to one.

• Myth #4.  The resolution threatens the Audiology and Speech-Language Pathology Interstate Compact for Virginia. The Virginia State Board needs to do what is best for the state of Virginia, not other states.  Since our state is now ranked 42 in terms of SLP ratio, Virginia is not really benefiting from the compact as-is. By taking the lead on a commonsense idea to improve the industry, we are going to get a flock of new speech graduates from all over the country ready to come to Virginia to work as SLPs. They will benefit from living in an amazing state, reduced administrative hurdles, and higher wages as they are able to start their career with full licenses as opposed to provisional ones. I am also confident that most other states will follow Virginia’s lead once this resolution is enacted. The compact should have to adjust to Virginia, not the other way around.

The ironic thing about ASHA’s opposition to this resolution is that they are resisting a solution to a problem they created….creating a class of professionals (CFs) whose ability to practice is interpreted and defined differently amongst every national regulatory agency (e.g., Medicare vs. TRICARE), state insurances such as Medicaid, private insurance companies, state boards, private practice, etc. Simply put, this process no longer makes sense, and the Virginia Board of Audiology and Speech-Language Pathology can provide a solution for our state and others to follow. 

The board identified licensure issues when it implemented the new six-month window to apply for full licensure earlier this year. I urge it to now go all the way and implement this common sense resolution to eliminate 18VAC30-21-60(A)(2)(c) so that the patients in Virginia in need of care can get it in a timely manner.

Philip Helman

CEO

Adler Therapy Group