CMS Just Exposed the SLP Certified Fellow Problem—Now What?

1:59AM Jun 16, 2025

Speakers:

Jeanette Benigas

Preston Lewis

Keywords:

CMS announcement

speech language pathology

clinical fellowship

provisional license

academic programs

mentorship

CMS policies

outpatient settings

insurance regulations

ASHA

state licensing

collaborative continuing education

petition

action items

job security.

Hey, fixers. I'm Dr Jeanette Benigas, the owner of fix SLP, a grassroots advocacy firm here to challenge the status quo in speech language pathology by driving real change from insurance regulations to removing barriers that prevent full autonomy like the CCC, this podcast is your space to learn, engage and take action in the field of speech language pathology. We don't wait for change, we make it so let's fix SLP!

Hello again. Fixers, here we are. We thought it was going to be summer break, and then boom, CMS comes out with some big news, and it has made the waves in our circle of speech language pathology this week. Jeanette, you're with me today. We have had a busy week. There are still questions. A lot of people are still trying to get their heads around this. In short, what has the Centers for Medicare services? What have they dropped upon us?

They dropped a really big surprise. We've got a lot of new listeners. So I'm Jeanette, host of the fix SLP podcast that was Preston, my co host, thanks for tuning in. Okay, so what they have done, they did not create new policies. What CMS has done is taken old 2015, policies that applied to home health only, and we should note there that it was in the regulation, but was never enforced. So I believe, and I don't have this in front of me, but I believe it was never placed into the CMS manual. So it was, it existed, but it wasn't being enforced. And what they did was in the process of updating all therapies, PT, OT and speech. What they did with speech was clarify that across the board, these policies now apply to all outpatient settings. And then they also tweaked the inpatient med a just a little bit. So that's across the board. They've existed already. These are not brand new policies. And so there's been something from a different organization floating around that there are no new changes. That is correct. These aren't new changes. They're just being applied in a new way.

Right now. It's like a question of, I think we're off on this island with our clinical fellows in our profession because our other allied health professions, whether it's PT, OT, you could even say audiology, they have baked into their academic process where, when their new grads are hatched out of the womb, and here they go, they're ready to Be fully licensed from day one. The standalone thing here is the clinical fellowship, because it's such a peculiar jigsaw piece. Jeanette, our other allied health professions of PT, OT even audiology, are ready to go from date of graduation, they have baked into their academic you know matriculation that they have that experience. There's no need for a provisional licensure. There's no need for this direct supervision, which CMS is now looking at, which is very impractical in most of your Medicare Part B delivery situations. So because we have that weird puzzle piece that, let's face it, is a product of ASHA for all these years, continuing to perpetuate this. Now, these clinical fellows are left with a lot of angst about, where do they go from here? And it's something Jeanette, you have talked about, which is and it's part of our plan. And people have said, You know what can fix? SLP, do you are discussing a plan. We're working actively about how to go about this, because this just landed at our doorstep. But the plan, the huge part of it is, let's go ahead and change the academic equation here so that these SLPs are ready to go from day one.

I'm seeing a lot of that discussion online. Let's just eliminate the CF. Let's just eliminate the CF. But here's the problem is that when our academic program was set up many years ago, when today's life problems weren't a problem, it was set up to include the CF to get people out into the workforce faster, but finish off their education. We don't live in those times anymore. And as Preston, very specifically, has said over and over and over, we need to modernize this profession, and this is why we've been saying it. I said you, you know the podcast you heard last week? I said the fellowship is dangerous. We've been saying this for two years, and we can't compare SLP to OT and PT, and here's why, at the end of their degree, speech pathologists have a total of 400 hours, 375 hours of direct client and patient contact, and then 25 hours of observation, which isn't even direct, so we'll just say it's 375 hours. OT ends with 960 hours or more, right? The this is baseline or more or more, three or 960 hours they have that's a lot. It's more than double. If you double what we have. We're only at 750 still, but they've got 960 and PT gets between 12 115 100 hours social work. I talked to a social worker about their certification process, they're up over 2000 hours. So this is one of those systemic issues why we have imposter syndrome, why new grads don't feel prepared, why everybody is always scrambling, why people don't understand what we do. Because when we're not prepared, we don't know what we're doing. This is the contributor to all the issues, and the issue at hand is we only get 375 hours. So that's why the CF was put in place to get the rest of the hours that PT and OT are paying for while they're still in school. So it's not a really good fight. Like, yes, we've gotten the degree, but when we're trying to fight now, we can't say to CMS, well, we're just as competent, because, no, we're not, we're not you guys. And so the supervision piece probably still needs to happen, but we need to fix it at the root level, at the ground level, which probably ultimately would be addressing our academic programs that will take decades. We're not at that point. So then, what can we do? Well, you see petitions floating around. Petitions make people feel like they're doing something. Sometimes they do things I think we have all seen, if you've been following fixed. SLP, they're often ignored.

Right now, that's the irony. Well, we, you know, we submitted one 6000 within the bylaws of ASHA, and it was roundly ignored. So I do the irony is not lost upon me that ashes first reaction is not necessarily an action plan to go along with a petition about how they can modernize. It's just, let's tell CMS to turn around. And that would be nice. I mean, for all of the clinical fellows out there that are nervous, yeah, sure, I agree with that, but we've known this is coming, and so a petition alone, I'm with you, Jeanette, it's

going to be ignored. They're going to look at it and laugh at it. And I said yesterday on social media, which probably most people missed, because it was in a story, is that CMS does not care about ASHA. CMS doesn't care about ashes certification or their process. That is ashes problem to figure out, they created that problem when they created their certification, and now they need to figure it out. There's been even more warning as we've gone along, and I've started to say this so you might have seen it, or maybe this is the first time what it comes down to here is this provisional or temporary license. That's the problem. The problem was created by ASHA when they created the CF, when they didn't just put make the academic programs correct and started training people outside of the academic program via the CF, that was problem number one, and it worked for a while, but as our nation plugged along, insurance agencies stopped credentialing people in their CF period, and so the states, as a workaround, started creating the temporary or provisional license, which worked for us as SLPs for A very long time, but it was a band aid because we weren't fully licensed. It was never set up to be a license, a full license again. It was a bridge or a band aid that allowed us to keep billing. And now insurance companies are trying to save money, and honestly, rightly so now they're coming back again and saying, This isn't a license. We can't allow this. But the problem is that it has been written into every state and DC, except for North Dakota. So I see a lot of people saying, do away with the CF. Cool, yes, let's do that. But one. Right? What happens to all of those training hours that we haven't gotten yet or are supposed to be getting? And two, even if ASHA woke up tomorrow and said, Okay, no more, CF, we still have to rewrite every single state license policy in this country. And that's the problem. It's not Yes, ASHA created the problem, but ASHA cannot fix this. Our states have to. Our states are in this now because they listen to ASHA, and then when the problem happened, where we couldn't Bill, you know, this was a problem in Pennsylvania for a long time. It took them over eight years to get a provisional license in their state. Practice Act. What's happening to CS across the nation right now? Happened to CS in Pennsylvania for decades. That provisional license just got put in place a few years ago. Pennsylvania should have just addressed the problem to begin with, but they didn't see it coming right? So it it's a problem where states have made this work around, and now CMS is saying, we're not letting you play like that anymore.

And, you know, people said, this is now this manifestation. It's probably coming from modern politics, which, you know, there's a lot of chaos out there, but as we've said, there was sort of a harbinger of this to come, going back to 2015 some people have said, well, licensure, you know, now is, you know, created, because now we have 50 state licensure that goes back 2012 so the groundwork was being laid, and it looks like, as a profession, we've just been kind of going through the motions to which, Gee, I wonder Why we have and what was the profit motive for one particular organization to do that. But putting that aside, we are in an era right now where there are clawbacks, whether it's private insurance or the government trying to make $1 into $1.10 and to cut things and to put it to the most stringent of you know, requirements. And I think that semantics do matter here. Jeanette, I've said it before, when you've got an organization that literally labels you as clinically competent after you've reached a certain point, then if I'm on the outside looking in, and, you know, people don't live in SLP world all the time, and I'm a government regulator, I'm saying, well, so those people aren't competent. Why would we want them billing for outpatient Part B services? It's, it's, you know, it semantics and words matter, you know, particularly in our profession, and we look very exposed here.

I've been saying it online all week. CMS called Ash's bluff, right? And Ash is not going to change. They're not going to change this because they would single handedly, be undoing the tower on or the platform of the tower on which they stand there, or floor one the foundation is the student supervision piece, but then floor one is this clinical fellow piece, and if they say, find no more clinical fellows, they're losing a lot of money. Going to lose a lot of money.

So the question is, what are we going to do? And Jeanette and I have, I mean, the the text threads going back and forth this week between the fix SLP team have been intense, and we always feel like we're having to start, you know, from the beginning, because we are, we're still new. And this week, we are going to reach out to CMS, right? We want to say, hey, please put a two year moratorium on this while we try to catch our breath and we go with this at a state by state level. So Jeanette, you laid out that plan so perfectly. I know there's a lot of moving parts to it. We're still trying to attenuate it because we want to ask in the right way. We want to communicate with the right people. Where are we on our plan?

Yeah. So first of all, we recognize that obviously our academic system needs fixed. That is the deepest route. We cannot do that. We can take that on in a later time. There are ideas for that, but we are not in a position right now with time, energy or money to take that on. That is a in five to 10 year from now. Plan. So what can we do today? Right now, we have chosen not to initiate a petition, because we know that that is words, not action. We need actionable steps. So the very first piece of this, and I'm very hopeful, by the time you are hearing this, we have already launched it, and you have already seen it on the internet. Because when you hear this, I'm laying on the beach in Florida, and I don't want to be writing letters to CMS. I'm leaving in 24 hours. In 24 hours, my team better get there together. Step one is we are going to ask all of you individually to reach out to CMS. We feel there is a much bigger impact there than a document of look. Electronic Signatures transferred in a file to CMS that doesn't make an impact. When they hear from you, the stakeholders, especially those of you who are losing your jobs, are about to lose their jobs, or afraid they're not going to get a job down the road, you have stories. If you are a supporter of fix SLP, and your family or loved one is being impacted by this. This is not just an SLP issue. This is now an access to care issue. If you are an employer who now has a problem filling a job because you're just not comfortable taking on the risk right now, and you've furloughed or laid off, or, I hope not fired, people are saying they're getting fired, in my hope it would be a layoff, but if you've had to let someone go, CMS needs to hear from you. They need to hear from the stakeholders who have boots on the ground and are being deeply impacted by this decision, a typed out signature with a state attached to it on a document does not hit the hearts. So we need people to send a hard copy to CMS. We are going to blitz them from all over this country, at every angle, and I'm really hopeful that our social media folks who aren't in SLP, but are adjacent, will share too, our OT friends, our PT, friends that know and see what's going on. We need everyone to send these letters. That's thing number one. And we're going to ask for a two year extension. We are not going to ask for a reinstatement. That is what ASHA is doing. This is my opinion only. I am sure my team agrees, but ASHA is going to submit that petition, and if they happen to be successful, which we don't think they will be, they're going to wash their hands of this problem and move on. They're going to count it as a win. They're going to move on. And you know what? The tower is going to crumble again. When this happens again, we just stand on the carousel and go around and around and the problem never gets fixed. So a reinstatement is a dangerous idea. Relying on the people who caused the problem in the first place to fix this is a bad idea. If we want to take our autonomy back, we have to go take it ourselves. So a two year extension seems reasonable. In some states, it could take more than that, especially if you've got legislators that are squirrely, or people on your state board who are Asha fans, it could, could be harder. But someone said, Oh, it took eight years for us to get a provisional license in. Pa, you think you can do this in two years? And yeah, naively, we think we can. And here's why, we are not putting in a new license. We are not putting in a new policy or procedure. Well, we are, but what we want to do is take the existing framework of the provisional license and the existing framework of the state license and mesh it together. So number one, maybe you rewrite what your your provisional period looks like, because we know there are a lot of issues with mentorship in this field, a lot of issues. It's time to write those wrongs. This is our chance. This sucks. What's happening, but this is a temporary problem to a solution that we we are going to change decades of jobs for speech language pathologists, if we can pull together and do this right. So fix your issues in the state with mentorship. Let's put it in the first year, or the first two years of licensure in your state. And instead of saying you take professional development or continuing education hours, we can call it something like your collaborative continuing education. That's it. You do what you're already doing in the first cycle, clean up the mess, fix the problems, maybe make more face to face visits or whatever. But then you this, the infrastructure is already there for reporting it. The infrastructure is already there for registering with your state. It's already there so you graduate, you get a full license, and you do these collaborative continuing education hours in the first cycle, or if they want to make that first year, then the first year, you do collaborative continuing education hours, and then you enter a regular two year cycle and do your CEUs. That seems like the simplest thing. We don't have to agree. And I think there's going to be a lot of disagreement over this, but personally, I don't think that mentorship should go away because of what we said at the top of this episode, as it relates to hours and people really needing guidance when they leave school.

It's a resource. It's a resource, and we need resources. They have given us a wake up call. This is. A cold bucket of water, and sometimes it doesn't feel good. It's going to be, you know, it's a sock in the gut, but it's also a chance to kind of wake up and sort of reassess ourselves, you know, kind of check ourselves. And that's the that's the call here. We need that resource, and perhaps it is needing that modernization. Because I don't know about some of you, but your mileage may vary on your clinical fellowship, mentorship, and it needs a refresh. It needs, you know, a retread and a rebrand. And we need to get to folks that are carrying a full license. And there are different ways. Also, I've been exploring how, like occupational therapy, does some of their hours calculations for their, you know, clinical experience that they've got coming out. These things should have been happening, but instead, it just always seems like we're just going to stand on one thing, which is this pathway that leads us on the yellow brick road to getting our certificate of clinical competency. And CMS has said, no, no, we're not. We're not comfortable with this any longer. We need something a little bit more well heeled.

I've said this already too, ASHA is more than welcome to partner with us on this. They probably will not, but in my mind, they should be looking right now at their policies and procedures with the CAA and what they do with students, because students need more hours, and the answer can no longer be the clinical fellowship. So how are we going to fix this and address this? CAA needs to get on top of it.

The profession has expanded. We now have more speech language pathologists than ever. There are opportunities out there. There are things with telehealth that are out there. There are more ways to integrate ourselves than ever, but we seem to be following this still anachronistic style,

And they're listening

yeah

You know, they're hearing this right now. Who knew they were following us on Tiktok too? I found that amazing. With not even 1000 followers on Monday, you know, I called out what happened, and within an hour and a half to two hours, you all got that email. So someone was watching on Tiktok, and they scrambled. And if you go look back at that email, there's some formatting errors there. So they definitely scrambled and put that thing together. Speculation, can't prove it, but certainly looks like that's what happened. So they're listening. They're hearing these ideas. We don't have to own these ideas. They don't have to belong to fix SLP. And also, these are just foundational ideas on how to build this framework. We're starting here with this suggestion in point A we are here to collaborate and fund efforts with every single state. But at the end of the day, every single state needs to do what's right for their state. We're not going to say, well, we're not going to help you or collaborate because fix SLP said, or that's not what we want. It's not up to us. We are here to reach the masses, to collaborate, to give you a way to organize and move forward in every state and take action. I think we have a lot of really brilliant people out there who probably have better ideas on how to do this than what I just said. And when people bring those to us, we can build those in and share them with everybody else. And I think there's a way forward in this that looks vastly different than how we're doing it right now, but lands us to a place where a new graduate has a full license and can still be supported in their clinical hours through their first year like they really do need because they've been not adequately prepared in school.

We need more than just the petition. We need more than just, oh, we're dialoguing with everyone. We've got it in there. That's a it seems so paternalistic, like, well, you children, don't worry. We will. We'll take care of this. Just go sign this, you know, card here, and I it's just, I think we're past that. I think it's well past the point that might have worked in 2015 but wow, we are. We're different now we we've kind of matured as a profession.

And and we have social media. The power of social media on our side, we can mobilize very quickly. We showed that this week, as of our this recording, we don't have our first call to action out yet, because there's only a couple of us on this team, and we've got a lot of responsibilities, and this was not scheduled on any of our schedules, so we're doing the best we can, but also we're very careful about what we put out. We're not just going to slap something out to make people feel better. We are doing our due diligence and looking at the options. If we're going to have you send a letter, we're going to give you the right place to send it. We need to make it right before we put it out there, because we never want to have to, and we sometimes we have to, but we never want to have to backtrack. We want to make it right the first time. Make it. Quality and make it good and make it effective. And that has been working for us as we have fixed Medicaid policy in three states, as we have gotten a bill on the Michigan floor that I will be testifying on behalf of and as of this recording 12 days, we're learning lessons and we're refining our process, but we have shown that our process is working and it's working well. We're showing that mobilizing these state teams is working and working well. And so we just need to replicate what we've been doing. So please give continued patience. I've seen online that ASHA is the only one doing anything for CFs right now. Okay, it's only been like four or five days, and we will be doing something, but we want to make sure we're doing it right. It's going to have to be action with CMS asking for that delay, so then we can mobilize these state teams to start making the significant changes where it matters.

Jeanette, I know you've got places you've got to go. We've got a busy day in front of us. This has been a great conversation, and it is summer, but we're going to keep moving forward like we always do.

Yeah, I want to give one more thing that I've continuously said before I sign off, and that is ASHA is saying, proceed with caution, maybe by the time this airs that will have changed. But for now, ASHA is saying, proceed with caution. If you're going to provide Part A and Part B services, do it as if you were a student. ASHA has a lot of smart people and a lot of smart lawyers. Talking to your supervisor is not a good idea. Your supervisor is not a lawyer. Your supervisor does not know how to assess risk. Your supervisor knows not much more than you do about this seasoned SLPs are not in a position to be giving CFS advice right now. CFS need to be listening to their company and remembering that their company is looking out for number one. So kind of assess how they're talking to you about this and how they've come to the decision that they've made. Take everything they say with a grain of salt. At the end of the day, what you really should do, if you have the means, is to consult a lawyer with good Medicare experience and then share that with one another, because there are 1000s of CFs across this country who don't have the means to do that, and if you share it with us, we'll spread the word, and we're here to support you. Also remember that this is not the end of the world for you. It feels like it in this moment, but many of us started in a pediatric private practice or a school setting or a pediatric hospital, and we are deep into our healthcare careers right now. I'm one of those people. My first three years was in the schools and in pediatric private practice, and now I own a mobile fees business. So there is a job for you in your preferred setting at the other end of this. It sucks, but it doesn't mean you're not an SLP, and it doesn't mean you can't get through this. And so, you know, securing a job, making your money, don't let those student loans lapse. Take care of you first, protect yourself in the way that you're most comfortable. And we are here behind the scenes working, and we're going to get this thing done together, because we've been putting on our posts since the beginning. #weareslp and this is our time to show it.

I was supposed to be the timekeeper for today. Jeanette, you really do have to get going.

All right, guys, we'll see you next week. Thanks for fixing it!