Early Steps in Florida needs to Revise their Policies for July 2019 in order for Agencies/Providers to provide services to the Birth to Three Population!

There are new Early Steps Policies coming into effect on July 1, 2019. We have a chance to complain about these new policies until April 7, 2019. The policies that are being made are making it difficult for agencies to provide services. Commercial Insurances do not pay for Developmental Delays in the state of Florida and the Early Steps Program is requiring us to bill commercial carriers causing us to not get reimbursed at all or for 5-6 months later for $5 or $10.00 a visit which is not appropriate to cover costs to run agencies and hire therapists. The new policy is saying that Early Steps would not be required to pay us the rest of the fee now or make it very difficult to get paid the rest of the rate. We can't just get reimbursed $5 or 10.00 or $0.00 for our services. Plus, the 60-day time frame they are giving us is also very ludicrous and causes a loss in reimbursement. That also needs changed especially when the year ends, we lose funds. Most insurance companies give us 90 to 180 days to bill and collect funds. To ask us to appeal insurance and provide proof of an EOB in 60 days is very difficult. It usually takes 45 days just to get the EOB in hand.

Furthermore, they are taking away the natural environment support fee for children seen in the daycare without the parent. Many parents work and can't be present. These children need services in order for them to improve their skills. The Early Steps Program of Florida is making it very hard to service these children with severe disabilities. There were also changes adding more certifications for ITDS's (Infant Toddler Development Specialist) who already undergone a lengthy process to just become a provider. We cannot incur additional costs. This program has been cut too much. There are too many challenges to make it worthwhile for any agency or provider to stay in business to serve these clients. It would be an unfortunate circumstance if there were no providers left for this program. Basically, this is what it is coming down to this time. We already must bill each Medicaid plan directly which also causes us further costs that we didn't want to incur. We were able to bill for free on the Medicaid web portal and now the state has made it very cumbersome to even serve these clients. We have too many administrative tasks/costs and not enough reimbursement for this program. Other states reimburse $125.00 or $150.00 per visit. Our reimbursement rates are way lower than that. The people in the Florida state office need to understand about billing medical insurance before they start making rules that they don't know about. 

Here are the revisions to the new policies and the comments and why it will not work. We also commented on what you need to do about it to revise it. 

Comments on the proposed changes for Early Steps in 2019 are not fair and adequate to provide the services the children with disabilities need in this state. The policies are unfair, and need revised immediately. 

1.4.4
A. The LES or service provider must bill public or private sources or third-party payer for direct services for eligible children and their families unless the family denies permission per policy 1.7.1.
B. LESs and Service providers shall not be paid Individuals with Disabilities Education Act (IDEA), Part C funds for direct services unless third party collection is denied by the third-party payer, and written evidence of denial is on file with the service provider. 
C. Part C funds may be used rather than billing insurance when the Early Steps rate for the service is less than the rate Early Steps would pay for the family's insurance copays and/or deductible.

Comment: 
Services should be provided by Part C dollars to ensure there is enough providers and coverage to offer services to families in need. Insurances do not pay for Early Intervention T1027SC they don't even recognize that code. Then for OT, PT, and ST services for commercial insurances you must be in network with that insurance to get paid. For example, Florida Blue you need to be credentialed as an out of network provider or an in-network provider to get reimbursed or you will receive nothing. Even if you are in network with that insurance they do not pay for developmental delays. All these children in the Early Steps program have developmental delays. The insurance usually must have the deductible met before they would even kick in anyway and they won't kick in and pay because they don't cover developmental delays. The CPT billing codes most often used are: F80.2, F80.1, F82.0, F88, Q90.9 etc. You are asking for the impossible. Basically, you are asking us to do free work. If we don't get reimbursed a dime from insurance, then we won't get reimbursed by Early Steps and this is not fair. You can't ask us to work for free. We would not be able to stay open and pay our therapists if you continue to go about the Early Steps Program like this. This is a government program that needs to be provided by this state as in every state in the USA. You need to ask for more funds from the government or find the funds somewhere because in this state the commercial carriers do not pay for Developmental Delays!!!

1.5.2 The Early Steps system will ensure that Parents are not required to pay any costs related to IDEA, Part C services, therefore: 
A. Parents are not charged any out-of-pocket costs for any Part C services.
B. Fees will not be charged for the services that a child is otherwise entitled to receive at no cost to the parents. 
C. The inability of the parents to pay for services will not result in the delay or denial of services to the child or the child's family.
D. All Part C services on the IFSP are available to the child and family whether or not consent to use insurance or Medicaid is required or provided.
Comment: 
Not sure what is going on here, but the parents are not supposed to pay anything either and when we bill insurance and they have an HSA account they are getting billed and this is why billing commercial insurance in Florida is not appropriate. Early Steps services and developmental delays are not covered by commercial carriers. Unless you change the law in Florida to make all the commercial carriers pay for developmental delays then the agencies and the providers are not going to be paid for their services and we can't keep doing free work. 

1.6.2 
A. When there is indication that public and/or private insurance is available to cover an IFSP authorized service, and the parent has not declined the use of that insurance, the LES or service provider must not bill or be reimbursed by Early Steps for that service unless the following is received: 
1. Denial of payment by the insurance company has been documented in writing on company letterhead or other written documentation from the insurance company or 
2. An Explanation of Benefits (EOB). 
B. When documentation outlined in 6.2.A.1 and 1.6.2.A.2 is not received, the LES or service provider must submit documentation that the payment by Early Steps is permissible per 1.4.6 a denial, EOB or written statement, is not available, the provider must submit documentation of all reasonable attempts to obtain these documents with the request for reimbursement.

Comment: 
How are IFSP meetings being covered? It should still be an Early Step Part C payer. Billing This is not a CPT code that insurances recognize. This is only an Early Steps code. Trying to get us to bill insurance and pay for services is ridiculous because if you have looked at the statistics, I am sure you would see that they do not pay in most cases for these services. We bill 92507, 92523 and T1027 SC and other PT and OT codes. Insurances follow the rules as if the parent will contribute their copay and deductible amounts. It does not follow rules of Early Steps.

Again, in the state of Florida private insurances do not pay for developmental delays. Many of the providers in the Early Steps programs are not even in network with many of these commercial carriers and they will not pay for developmental delays. We can't get on these insurances. Their panels are closed. They only want big companies and still, in certain areas, their panels are closed. So, the state doesn't understand how billing works and doesn't understand how we are not getting paid by commercial carriers for our services. Even if we were in network (with United Healthcare for instance) and they paid for Speech Therapy, they would only pay $10.00 and expect the parent to pay the rest. Well the insurance doesn't understand that the kid is in the Early Steps program and now your new policy says WE CAN'T COLLECT THE REST FROM EARLY STEPS? WHY? DO YOU EXPECT US TO ONLY GET PAID $10.00 OR $0.00 FOR PROVIDING EARLY STEPS SERVICES TO THE CHILDREN IN NEED IN THIS STATE? THIS IS WHAT YOU ARE ASKING OF US. THIS IS REALLY UNETHICAL OF THIS PROGRAM TO MAKE THESE KINDS OF POLICIES WITHOUT UNDERSTANDING THE IMPLICATIONS YOU ARE CREATING. 

1.6.3
A. When the family consents to bill their private or public insurance, the service provider must pursue all insurance denials of service coverage unless the insurance company's policy is very clear, and it has been confirmed that a particular service is not covered or is only covered for a specific number of sessions.
B. There must be documentation in the Early Steps record as to the circumstances that led to the decision not to access the family's insurance for the reasons in 1.6.3.A.

Comment: 
We can't call the insurance and find out if it is not covered by the plan. It takes hours waiting on the phone to get a live person. The representatives can't say if it is covered or not. You must be specific with the diagnosis and the codes and they still won't give you a straight answer. You can't even get a live person on the phone at Florida Blue. Again, this takes many months to go through denials and we will not get paid because Developmental Delays are not covered by Commercial Carriers!!!!!! PLUS, YOU ARE ASKING US AGAIN TO DO FREE WORK FOR MONTHS BEFORE GETTING REIMBURSED TO SEE THE BIRTH TO THREE CHILDREN OF THIS STATE WHO ARE IN NEED OF SERVICES. IN ESSENCE YOU ARE DENYING THEIR RIGHTS TO GET SERVICES BECAUSE THERE WILL NOT BE ANY PROVIDERS LEFT BECAUSE WE CAN'T DO FREE WORK FOR MONTHS WITHOUT REIMBURSEMENT. 

1.6.7
A. If a LES or service provider does not receive payment from an insurance company, the following steps must be taken: 
1. Ensure the proper billing procedures were followed, 
2. Review the diagnosis code(s) to determine if it was correctly submitted to the insurance company, and
3. Determine if additional documentation is necessary to successfully obtain payment.
B. A claim must be resubmitted if any of the circumstances in 1.6.6.A. are identified as necessary to obtain payment.
C. Early Steps funds shall not be used if the LES or service provider fails to follow the steps in 1.6.6.A. and 1.6.6.B Disallowance of payment for failure of the provider to follow proper billing procedures, incorrect diagnosis code or other correctable reasons for disallowance by public and private insurance will not constitute grounds for payment from Early Steps funds. 

Comment: 
Not sure what is going on here, but again commercial insurances do not pay for developmental delays and all the children in the Early Steps Program have developmental delays and you are asking for us to do free work. We need reimbursed by the Early Steps program in order to get reimbursed for our services. This is the IDEA Law which is an Individualized Disability Education Act not a medical model.

10.5.5 Individual providers may enroll as an early intervention provider in only one of the professions listed in Chapter 1 3 of the Florida Medicaid Early Intervention Services Coverage Policy Handbook and Limitations Handbook, even if they hold licenses in more than one of those professions. An early intervention provider may not be enrolled simultaneously as both an Infant Toddler Developmental Specialist and a licensed practitioner

Comment: 
There are Speech Therapists, Occupational Therapists and Physical Therapists who are also Early Interventionists with the taxonomy code 222Q00000X in addition to their own taxonomy codes to be an ST, OT, and PT. Are you saying they can't be dually enrolled now? This is not fair because we have undergone this for certain Early Steps, and we have both Medicaid numbers and taxonomy codes under our name. It helps me to be a Speech Pathologist and an EI with taxonomy code 222Q00000X because I can get kids on my caseload and then hire an ITDS to take over the caseload. That way when I hire someone, they have a full caseload already instead of waiting months to get full time work. Some kids are already receiving ST, OT or PT at an outpatient clinic and could also receive Early Intervention services from a licensed provider as an EI taxonomy code 222Q00000X. This provides more services for the child that has severe delays when they are in the Early Steps program and receive private outpatient clinic-based services.


10.6.5 Reserved All Infant Toddler Developmental Specialists must renew their ITDS certification every three years from the date of their last certification. Such renewal includes: 
A. An updated background check, 
B. Ongoing professional development in the form of team meetings with a licensed provider for at least 8 hours per year and held at regular intervals, and 
C. Continuing education that includes: 
1. A minimum of 24 hours of Continuing Education Units (CEUs) in relevant classes taken within the current credentialing period, or 
2. A minimum of 12 hours of CEUs and in-service hours that meet the requirements in Guidance 10.6.5.B.1 to total 24 hours. Operations Guide 10.6.5
Component 12 – Data Collection/Reporting and Record Keeping

Comment: 
So, where are these ITDS's going to get their coursework from? How much is this going to cost them? We don't make enough money to undergo more hoops and increased costs to just be an ITDS when we were qualified to be that in the first place. They met all the requirements needed. If the local early steps also provided additional training for free that is fine, but to make us pay more money when we have already been cut so much is unfair. Plus, ITDS's drive around to see clients and they need reimbursed for their drive time. They see about 6-7 kids a day and if you are asking them to do additional CEU hours that is also cutting into their pay checks. They will be out of compliance seeing their children. Then they will be out of money because they must pay for courses to go to keep their certification. Where are these courses they need to take? Who is offering them? Are they required to repeat the same courses every 3 years? We need additional information here. Plus, we don't want additional costs because our pay is too low already for this. Please consider this in your policy changes. Please do not make these policy changes because of all the costs that will be involved with these changes as well as lost funds to attend CEU courses etc. These ITDS's are non-licensed providers who should not need CEU hours to provide services. The local Early Steps and agencies already monitors these providers to keep them in compliance.

12.6.2 
A. Local Early Steps may pay a natural environment support fee to providers who are serving a child face to face in their natural environment. This support fee will be in addition to the payment the provider receives for services to the child. 
B. The natural environment support fee can only be billed when the service or IFSP meeting is in the natural environment and the child and parent is present it is related to the provision of a service, IFSP meeting or consultation session. 

Comment: 
The natural environment support fee is supposed to be paid to the Early Interventionist/ITDS, ST, OT, PT etc. that goes to see the child in the natural environment. This means they are not seeing this child in a clinic setting. So, the providers need to be paid for their drive time to go see this child. There is about 15 to 20 minutes in the car driving usually and already the NESF is not enough to cover the cost in the car. They make more money seeing children than the cost in the car. The ITDS's also have a ton of paperwork and phone calls to make to make appointments with parents/caregivers. There are a lot of processes that are not paid for such as their documentation, progress monitoring reports, calling parents, etc. You also must understand the overhead costs of the agencies who hire these providers and how we need to make enough money to hire these therapists. So, to get rid of the NESF fee because the parent is not present is not fair. That fee is to go to the provider. Many parents work and providers see these children in a daycare. These children will be without services otherwise. This needs to be revised and you need to keep the NESF for all kids seen in the natural environment with or without the parent present. The NESF fee should be reimbursed if the caregiver (Mom, Grandma, babysitter, etc.), the preschool or daycare teacher, the child and the provider are present. This is a fee that should remain because the provider went to see this child and the child was present, with a caregiver, in their natural environment. Please keep the NESF in all-natural environments. 

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Natural Environments - The day-to-day routines, activities and places that promote learning opportunities for an individual child and family. This means settings, including home and community settings that are natural or typical for the child's age peers who have no disabilities. In the context of service delivery, natural environments further mean settings in which the child and family are present.

Comment: 
Again, many children who have working parents would not get services through the early steps program if you take away seeing the child in the daycare as the natural environment. We also see kids in parks and other places if they can't be seen in the home. Sometimes Grandma, Grandpa or a babysitter are present. This is not fair to the children either. The children will not get services because you expect the parent to not have a job so the provider can get paid in the natural environment. This is not fair. Natural environment is where the child is at and it includes the provider and the child and a caregiver of some sort not always the parents. Please revise this policy and make it available to see the child in a natural environment even if the parent is not present. These kids already have delays and now you are making it hard for us to serve these children and help them. You are making it hard for us to hire therapists to see them. If we can't get reimbursed for what we do, then why do it at all? This is not the purpose of this program to cut funds and make it difficult for everyone. The purpose of this program is to serve the birth to three population with disabilities. Please revise this policy to include that the natural environment is where the child and provider is located with any caregiver present. 

Summary about all these policy changes:
Please revise these policies and make it fair for agencies to hire therapists. We would like it if you could make it easy for us to pay our therapists to give them a reasonable and customary wage. The more cuts and rules you are making will be making it difficult for us to hire and maintain the therapists to serve these children. Please take that into consideration. Also please take into consideration that insurances do not pay for developmental delays and you are asking for us to do free work. Many plans have high deductibles and the chances of them reimbursing anything is slim anyway if they even covered developmental delays. You are also asking for us to not get reimbursed for 5-6 months and that is too long to go without reimbursement. To appeal insurances that do not recognize T1027 SC or do not pay for developmental delays is causing us a lot of lost funds. We can't stay open with these kinds of problems. Please revise these policies. The Early Steps program should be paid by Early Steps. Otherwise the state of Florida needs to make a rule that all commercial and Medicaid insurances need to pay for these services no matter if the provider/agency is in or out of network with that insurance plan. Many insurance plans have closed their panels and we can't even get on them. The Medicaid insurances of Florida should remain at the 100% Medicaid rates for Early Steps services and not also let these ATA/HN1 companies dictate a lower rate. You should model Virginia or Massachusetts on how they run their Early Steps programs. 

Please sign the petition and add to your comments about how these new policies and how the whole Early Steps Program in Florida needs to be revised to make it possible for us to provide services to these children. More Government funds are needed for this program for it to run properly. The Early Steps Program of Florida are asking for commercial insurances to pay and they are not required to pay and will not pay. There are no other funds except for the Early Steps program. If the Early Steps Program is deficient in funds, then you need to ask for more. Otherwise, there will be no providers left to provide services to the children with severe disabilities in the state of Florida.

Thank you for your time and consideration in this matter. 

Sincerely,

Early Steps Agencies, Parents, and Providers of Florida as well as the concerned citizens and providers of the USA.