Today, depending on the disorder and severity, some kids are able to receive both school-based therapy and outpatient, or insurance-based (medical model) therapy, and though they may be getting treating for basically the same disorder, the process and qualifications to determine eligibility are somewhat different. Therapists within the school are looking to qualify children under the educational model of service delivery. These children qualify for services based on the impact their disorder may have on their educational achievement or their ability to navigate the school environment. This is one reason why school-based Speech Therapists do not provide feeding therapy, as it is not related to educational performance. Therapists providing services under the medical model (outpatient) of therapy are looking to qualify patients based on how their disorder impacts their whole life. These evaluations must be written to address the patient’s ‘medical necessity’ for therapy.
Both insurance-based and school-based therapy begins with the administration of tests, during an evaluation, which is used to compare the performance of the patient to kids the same age. The actual test score needed to qualify for services may vary from school district to school district, and from one insurance provider to another, but the typical standard score most professionals qualify by is 85 or less on a standardized test. Evaluations completed under the educational model may or may not rely on the use of standardized tests, in combination with teacher and parent reports and classroom observations, while evaluations completed under the medical model tend to rely more heavily on standardized measures to prove medical necessity.
Goals set from the evaluation, within the educational setting are also sometimes written differently than goals set within the outpatient (insurance-based) setting. Goals set for school-based therapy may address some component of classroom performance, such as, “During a structured classroom setting, Patient A will produce /s/ at the beginning of words with 80% accuracy, as measured by clinician/teacher observation,” while goals written for insurance need to be more functional and address the patient’s performance across settings. An example of a similar goal written under the medical model, could be “Patient will produce the /s/ at the beginning, middle and end of one-syllable words with 80% accuracy, during conversation.” The goals are basically addressing the same skill, but are worded slightly different, to account for the different settings and funding sources the evaluations must go through.
Evaluations and services completed within the school-setting are typically covered by the school district, unless the parent has supplied the school with insurance information and authorization to bill the services delivered in school, to their insurance company. If this is done, it prevents the child from being able to receive services at both school and an outpatient clinic. Evaluations and services delivered under the medical model are billed to the patient’s insurance company. Another important difference is that services delivered under the medical model that are going to be billed to an insurance company must have a referral from a doctor before any service can be delivered, while educational-based services do not require doctor’s orders.
There are many factors to consider when planning a therapeutic path for your child and it helps to know the different routes available that you may be able to take to get services. It does become confusing however, once you hear discussions about educational versus medical-based therapy and not knowing the difference and how it may impact your child’s therapy and goal-setting. If your child is receiving services from both a school-based therapist and a private therapist, be aware of the different goals your child is working on in both settings. Also, let both therapists know that there is another therapist working with your child and share their evaluations with each other, so that they are aware of what their patient is working on with the other therapist. The collaboration may help reduce redundancy and help your child to meet their goals faster, and who doesn’t want faster progress?