Telepractice A Clinical Guide for Speech-Language Pathologists (Melissa Jakubowitz, Lesley Edwards-Gaither) (z-lib.org)

136  Telepractice:  A Clinical Guide for Speech-Language Pathologists

the rules and regulations in one state at a time, until there is enough
income to hire people to assist with the process.

In the case of “ABC Teletherapy,” the solution statement might
be, “ABC therapy provides speech and language therapy services that
are convenient to families via a telepractice model.”

Knowing your competition is crucial to ensure the health of
any business. When or if the time comes to obtain funding, potential
financial entities or investors want to know that you are aware of
the competition and what separates this business from competitors.
The Competition section for ABC Teletherapy might read, “Provid-
ing speech and language services to the early intervention market is
part of a niche market. Large companies such as XYZ Therapies, 123
Speech, and MySLP provide services across the spectrum of ages and
disorders. Smaller companies provide the same services, but locally,
and only in the home.”

Revenue streams include how you will generate income for the
practice. Will it be private pay only, will insurance be accepted, or a
combination of both? Knowing this information assists in planning to
ensure revenue will be greater than expenses. For ABC Teletherapy it
would be “ABC Teletherapy will sell their services directly to parents
of children with special needs and contract with the state early inter-
vention agency.”

The Marketing Activities section is the place to list how you will
market to your potential clients. ABC Teletherapy lists their market-
ing activities as follows: “ABC Teletherapy will communicate with
potential customers through e-mails, targeted Google and Facebook
ads, and other social media. They will attend early intervention con-
ferences and exhibit the company at those conferences.”

Expenses include everything that is the cost of doing business. In
the sample case of ABC Teletherapy, this would include office space,
computers, videoconferencing platform, advertising/marketing, and
a virtual assistant.

The team and key roles include the owner of the company and
any other officers of the company. In addition, depending on the size
of the company, there may be a marketing person, and a salesperson.
For those SLPs just starting out, this is typically the owner/founder of
the company who does it all until the company grows beyond one SLP.

6.  Telepractice as a Business  137

Finally, there is the Milestones section, where the goals of the
company are stated. These goals should be measurable to assist the
owner in determining when to grow or sell their business. In the case
of ABC Teletherapy, the goal is to grow to 20 clients through mar-
keting to parents, and to help obtain contracts with the state early
intervention agencies.

Using a business plan as a road map facilitates growing a practice
effectively and efficiently. Business plans do change as the business
grows and also when business is not going well. The plan helps the
owner take a hard look at the facts and compare them to the plan. A
smart owner will make adjustments as needed to push the business
in a positive direction.

Setting Therapy Rates
Setting a rate for therapy services is a hot topic. New business owners
need to be careful about how they go about setting rates, as setting
it too low will result in the business losing money. If rates are too
high, then there is the potential to lose business to a lower-priced
practice. Consulting with other business owners about their rates may
be helpful, but it is not where the business owner should start.

To set appropriate rates for a solo practitioner, start with a list
of all of the business’s monthly expenses. This would include items
such as office space, equipment and supplies, computers, internet
access, licenses and permits, utilities, insurance, lawyer and accoun-
tant, advertising and marketing, developing a website, and any other
ongoing costs of doing business (SBA, n.d.). Figure 6–1 is an example
of how to calculate hourly rates.

When monthly costs have been calculated, the SLP determines
how many hours per week they are able to provide direct therapy.
(Make sure to include time for paperwork, marketing, billing, plan-
ning, and accounting). The number of hours per week is then multi-
plied by 48. Forty-eight represents the number of working weeks in
a year. This number allows for 10 federal holidays (which are typi-
cally not workdays), and 2 weeks of vacation. The sum of the hours

138  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Session Fee Analysis Example 100,000 A

Target Net Income 3,500
5,000
Operating costs: 2,500
1,500
Accounting fees 2,500
Continuing education 2,000
Dues 3,000
Insurance malpractice 3,000
IT services 24,000
Licenses 1,000
Marketing 5,000
Office 1,200
Rent 2,500
Subscriptions 1,500
Supplies
Telephone 58,200 B
Travel/auto
Utilities 158,200 C (A+B)

Total income needed 150 D (?)

Fees charges per session 1055 C divided by D

Sessions needed 48 E (?)

Weeks Worked 22 C divided by E

Sessions per week needed

Figure 6–1.  Compensation calculator.

available to provide services, multiplied by the number of weeks per
year, reveals the total number of billable hours. Take total expenses
for the year and divide by the number of billable hours. The sum will
be the hourly rate that will cover the costs for the year. If the SLP
would like a larger profit, then the rate would need to increase.

It is helpful to compare this rate with other, similar practices,
both within and outside the state. By looking at other practices’ rates,
the SLP will know if they are in the same ballpark, and are reasonable

6.  Telepractice as a Business  139

compared to others. Make sure that the practices that are used to
compare rates are similar in size and scope to the owner’s business.
For example, if the business the SLP is establishing is a solo practice,
comparing it to a large, established telepractice company with 50
employees is not equally comparable. The larger company will have
higher expenses than a solo practitioner. Likewise, if the owner has
10 SLPs already working for them, then the comparison should be
with similar-sized operations because expenses are likely to be similar.

A frequently asked question is how to determine other practices
hourly rates. There are a few ways to accomplish this. First, some
practices post their hourly rates on their websites, so this is the place
to start. Often, practices will share rates on social media sites when
asked. However, it should be noted that asking other practices directly
about their rates could potentially be construed as price fixing. Asking
a SLP business owner’s in-state attorney about this issue would help
to clear it up and provide give guidance on how to go about getting
these rates.

When the focus of the business is on contracting with public
schools, that information is often public. School contracts are
approved by the school board and are frequently found in the minutes
of the school board meetings. With some searching through school
board minutes, one can often find the approved contracts there.
Again, it is important to look at the size of the contracting company
when comparing rates.

Determining whether or not to bill insurance is a decision that
needs to be made based on two factors: (1) is the insurance reim-
bursement enough to cover the practice’s hourly rate, and (2) how
long will it take to receive reimbursement? A clinician should not
contract with an insurance company if their rates will not afford a
profit, even a small profit. The other important factor is whether or
not the local average income will support a cash only practice. Taking
the time to research the communities that the telepractice company
is focused on is important, particularly if the focus is on private pay.
The research is easy as this information is available online simply by
using a search engine.

Setting rates at a fair price while ensuring a profit is important.
The reason many SLPs go into private practice is because they want

140  Telepractice:  A Clinical Guide for Speech-Language Pathologists

to make a better wage. SLPs are not taught about running a business
in graduate school so they need to learn about how to run a business
on their own (or go back to school and get a degree in business!).
SLPs need to learn how to collect money from clients without feeling
uncomfortable. Clinicians often have a difficult time collecting money,
particularly when a client claims to not have the money or needs an
extension. Think about going to a physician or dentist’s office. They
immediately collect the patient’s copay. This way, they don’t have to
chase after a patient at a later date. It helps with cash flow and ensures
the owner is not spending valuable time chasing down payments.

Marketing for Private Clients
Marketing is an important aspect of any business. Without marketing,
it is not likely that the business will attract clients. It is critical to have
an online presence. Building an attractive website is an important
marketing tool that helps potential clients to find your business. Using
social media, sending e-mails, and blogging are all considered mar-
keting tools. Even word-of-mouth is considered a type of marketing.
Knowing your target market is critical to the marketing plan. If the
SLP does not know who their target market is, then the time and
energy spent on these activities will not yield results. Tracking mar-
keting efforts and results will determine if these strategies are effective
and bringing in clients. Don’t waste time or money on marketing that
does not work.

For those practices that are focused on private pay clients,
finding out where clients “hang out online” is important (Murray,
n.d.). For example, if you are looking for preschool clients, research-
ing Facebook groups with mothers of preschoolers or toddlers would
be a good place to start. If adult clients are your target, you need
to consider where they hang out online. Taking time to figure out
where your ideal client is spending time will assist with focusing your
marketing dollars. Knowing when you are out of your depth (Murray,
n.d.), may be the time to hire a professional marketing consultant.
SLPs may not be experts at everything. SLPs are fantastic at evaluating

6.  Telepractice as a Business  141

clients, planning and executing treatment, and working with families.
However, they may not know much about marketing. Sometimes it is
far more productive to hire someone to assist with this aspect if it is
not an area of your strength, or there is limited time to learn because
you, the owner SLP are also treating clients.

When marketing the business, the owner’s passion is critical to
customers. If the advertisements and marketing efforts don’t impart
this passion, it could decrease the effect of the marketing efforts.
SLPs should ask themselves, why am I passionate about this work?
What sets me apart from the rest of the practices in my target market?
Showing passion and enthusiasm goes far to attract clients.

When marketing to private clients, there are a number of steps to
improve internet search engine optimization (SEO) online. Once the
business website is set up, using “Google My Business” is one way to
improve SEO. This is one way to get your business to pop up higher
on a Google search. The business website should include the search
words used in the “Google My Business” registration. In the body
of the website, you want to include words such as speech therapy,
speech and language therapy, speech disorder, language disorder, and
so forth. If the business specializes in a particular population, whether
it is an age group or specific disability, include the terminology that a
family member or individual might use to search for those particular
SLP services. Also, look for websites that are relevant and where the
business could advertise their services to populations that would have
an interest in the SLP’s services.

Facebook ads and Google ads can be effective. Again, monitoring
and tracking the data on click-throughs are important to determine
whether or not the ads are effective. In the beginning, ads will need to
be tweaked or changed depending on responses. Posting comments
in Facebook groups that are relevant to the target population can
be helpful, but be aware of the rules of the group before posting a
message about your business. It is better to respond to questions
about speech and language development without selling your business
product until asked about it.

Establishing a Facebook, Instagram, or Pinterest pages specifi-
cally for the business can be helpful if the owner is actively posting on
these sites. Writing a blog on your website and sharing it on Facebook,

142  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Instagram, and so forth, is helpful for visibility for the business. If
the owner doesn’t have time for regular blogs, then sharing relevant
blogs, videos, or articles of interest is also effective. Currently, there
are many blogs, videos, and articles written by other SLPs that it may
not be necessary for the owner to post as often. If another post is
relevant, it is easy enough to share with others as long as you get
permission from the original writer.

Traditionally, SLP brick and mortar practices have used paper-
based materials to drop off at doctor’s offices, preschools, private
schools, and so forth. For a telepractice business, this might be more
difficult to do unless the business is focused on a local area. In any
promotional material, it should be clear that the business is remote
only. If that is not spelled out, it may lead to disappointment on the
client’s part, so be clear in any promotional materials.

There are numerous avenues for marketing a practice. The owner
should carefully choose where to target their marketing dollars and
monitor results. If one avenue is not working, it is time to move on
to another type of advertisement. Once the practice is established, a
steady flow of clients is easier to obtain due to word of mouth. Word
of mouth is one of the best ways to advertise particularly, if the SLP is
good at what they do. Families talk to each other and will recommend
their SLP if their family member has had success with treatment.

Marketing to Schools
Marketing to schools is different than marketing to private clients.
Whether a sole proprietor SLP business, or a larger practice adding
teletherapy, persistence is the key to obtaining contracts with schools.
The key to successful marketing to schools includes knowing who
the decision-makers are, targeting the right districts, demonstrating
value, growing your network, and building relationships.

In public school districts, typically the Special Education Direc-
tor is the decision-maker for hiring a contract company to provide
services. There are other titles that may be used for this position,
such as Special Education Coordinator, Director of Pupil Services,

6.  Telepractice as a Business  143

among others. It is easy to find their title on school district websites.
The Special Education Director is the person to target, although
often, once they have decided on a company, the contract needs to be
approved by other people, such as the Director of Human Resources
or an Assistant Superintendent, or Superintendent. The Special Edu-
cation Director is the first point of contact.

In marketing to schools, the first step is finding districts with SLP
openings. There are several, easy to access, internet websites that post
job openings in schools. Openings are also listed on school district
websites, but these take time and energy to find the openings. There
are companies that will sell lists of school personnel (Superintendents,
Special Education Directors, etc.) and their contact information, but
these can be pricey for an SLP just starting out. Using the school job
websites is a good place to start. While looking at the job postings,
targeting the districts with the oldest dated postings is a good place
to start. These are the districts that have been looking for more than a
few months for SLPs and may be more willing to contract for teleprac-
tice services.

Prior to the pandemic, it was difficult to convince school per-
sonnel to use telepractice, as the preference was for an in-person SLP.
There second preference was, typically, contracting with a company
for in-person services, and finally, telepractice was the last resort.
As the knowledge, research, and utilization of the telepractice model
increased, it became somewhat easier to talk to districts about this
service delivery model. Since the pandemic, it is still a mixed bag
of responses to teletherapy. In those districts where the SLPs were
successful with telepractice, they were more open to continuing with
this model; where it wasn’t as successful or where parents of students
were unhappy, it was less likely that they would continue to adopt
telepractice. Either way, most districts continue to prefer an in-person
SLP. One way to overcome this hesitancy is to offer a hybrid model
where the SLP provides teletherapy most of time, and travels to the
district every six to eight weeks for a few days of in-person services.

Selling teletherapy to schools often requires a two-pronged
approach. It is a combination of e-mailing and cold calls. For most
SLPs, sending e-mails is easy. Cold calling is much more challenging
and takes some practice to feel comfortable at it. Many SLPs are not

144  Telepractice:  A Clinical Guide for Speech-Language Pathologists

comfortable selling themselves or their practices so it takes fortitude
to get past this in order to be successful. While the e-mail introduces
the company to the Special Education Director, they may not have
read the e-mail. Remember that the Special Education Director is
receiving e-mails from numerous companies looking to contract with
them, so they often skip these emails. Having an interesting subject
line and brevity is important. The e-mail should be no more than
three paragraphs. The first paragraph is the reason the company is
contacting the school district. The second paragraph is an introduc-
tion to your business and how it is different from other companies.
And finally, the third paragraph is a call to action. A call to action
is asking the Special Education Director to call the SLP to discuss
a contract.

There are a variety of software applications that can be purchased
to assist with sending mass e-mails. As the SLP is looking for districts
with openings, this information can be collected in a spreadsheet con-
taining contacts and pertinent information (phone number, e-mail
address, etc.), thus making a “mailing list” easy to send. These appli-
cations allow the user to write one e-mail that can be personalized for
each district in one easy step. This method is much more use-friendly
than pasting an e-mail in numerous, separate e-mails. Some software
applications assist with tracking whether or not the e-mails have been
opened. Knowing that an e-mail has been opened and read gives the
SLP a clue that this district should be put on the SLP’s call list, as they
may be interested in a future contract.

Cold calling can be intimidating for business owners with no
information or previous experience. However, it is a skill that can
be learned. It is a matter of scripting your pitch and practicing many
times so it sounds natural. For some people, rather than scripting
their conversation, it may be better to list bullet points. This can
sound more natural but it still takes practice.

When calling Special Education Directors, it is important to
keep the initial conversations brief—fifteen to twenty minutes—as
their time is valuable. In this conversation, the SLP needs to demon-
strate their value to the district. Explaining what sets your company
apart from the competition is critical to making a sale. If the SLP
has worked in schools in the past, it is helpful to note this. Directors

6.  Telepractice as a Business  145

of school districts might favor SLPs who have experience providing
services in schools, as they will understand school-based practice and
how it is different from other practice areas. Knowing the rules
and regulations for special education services is critical to success and
demonstrates the unique value of your company. Those directors need
to be confident that your skills and abilities will benefit their students.
If you have references from other districts your business has served,
this is the time to offer those references.

If a Director says “No,” do not take it personally! This is hard
but the best salespeople hear “No” as a challenge to do better next
time. If this is the case, ask if you can follow up in a few months to
see if they still have a need. Always be polite, and then make sure
there is follow-up if the Director indicates they would be willing to
talk again in the future. The SLP may call ten districts a day and not
obtain any interest in contracting because the district may be waiting
for an in-person SLP. After a few months, if they have not obtained
an in-person SLP and parents are getting anxious about their children
not receiving services, a call back is helpful as the district may be more
willing to contract for telepractice services.

Growing a network and building relationships helps with future
contract possibilities. To grow a network of specific names, the SLP
needs to keep track of where Special Education Directors and other
stakeholders (superintendents, etc.) go. These individuals have orga-
nizations similar to the American Speech-Language-Hearing Associa-
tion (ASHA) and offer conventions annually. There are both state and
national versions of these organizations for these individuals. SLPs
can attend these conferences as exhibitors, attendees, or presenters.
Some of these organizations offer time on the program in exchange
for a sponsorship.

If the SLP has limited funds to attend a convention as an attendee
or exhibitor, it is often possible to buy admission into the exhibit hall
where networking is possible. For example, at the ASHA convention, it
is possible to buy a guest pass for admission into the exhibit hall where
many school districts have a booth and are hiring SLPs. Networking
with the individuals manning these booths is an excellent way to
connect with district personnel. Sometimes those staffing the booths
are the Special Education Directors, sometimes they are personnel

146  Telepractice:  A Clinical Guide for Speech-Language Pathologists

from Human Resources, or even SLPs from the district. Initially they
may not be interested in your services, but if you ask for their business
cards or contact information and follow up a month or two later, you
can determine if they have hired anyone. Develop a relationship with
these individuals, and as they begin to know and trust you, they might
eventually contact you when they need your services.

Knowing and understanding school district sales cycles will
go a long way in how and when to contact schools districts. Most
school districts across the United States operate on a July 1 to June 30
fiscal year. This means that budgets are typically approved around
March or April for the new fiscal year. Special Education Directors are
looking at staffing around this time frame as well. They are making
projections regarding incoming special educations students as well
as looking at how many are graduating. Attrition is also taken into
account for those students who may move in and out of districts. The
director then looks at staffing and whether or not they need more
SLPs or other special education providers. As districts begin to look
at their needs, they will post job openings around this time of year
for the following school year. This is a good time to contact directors
to market your business. Although they may not be ready to hire just
yet (as most districts prioritize in-person services and hiring employ-
ees rather than contractors) this is a good time to get to know these
directors and let them know you have availability. If a district has a
chronic shortage, they may very well develop a contract at this point
because they know from previous years it is difficult to attract SLPs to
their district. From March through July, districts continue to look for
employees to fill open or new positions. If the SLP is not successful
between March and July in obtaining a contract, it is important to
continue their marketing push.

From August to October, when many schools begin the new
school year, districts may still be looking for SLPs but are still hoping
to hire employees. Also, the beginning of the school year can be quite
busy for the Special Education Director and some of the hiring may go
by the wayside. By Labor Day in September, most new SLP graduates
have jobs and those that want to switch jobs are also employed, making
it easier for contractors to find contracts. In addition, if parents realize
that SLP services are not being offered to their students, they may

6.  Telepractice as a Business  147

be contacting the Special Education Director to find out when their
child will receive their IEP services. Once again, this is a good time
to contact districts that continue to have openings, as these districts
don’t want to owe too much compensatory time.

From November through January, things slow down somewhat
in terms of job openings. However, the end of the first semester tends
to be a time when SLPs who are planning on taking a medical leave
tend to give notice, thus leaving mid-year openings that are much
harder to fill for school districts because most SLPs are fully employed
by this time of year. This does not mean that the marketing efforts
should slow down, but should focus on unexpected leaves, or mid-
year openings. It is a matter of changing the focus of e-mail campaigns
and cold calls.

The final time period in the year is January through March. The
focus of marketing should continue with those mid-year openings
that are hard to fill. In addition, if the SLP has contracts, this is the
time of year to start conversations about continuing contracts the
following school year. Because there is some competition for these
contracts, checking in with the Director to see how things are going
and starting the contract talk for the following school year are import-
ant, and this is the time to do so.

Schools in some states have a Request for Proposal (RFP),
whereby the SLP needs to submit a proposal to the district. The RFP
typically asks about the kinds of services the SLP company has to
offer, the credentials of those providing the services, and other infor-
mation about the company. These can be relatively short (three to five
pages) or they can be more in-depth or complex. Frequently, the SLP
company will need to show proof of liability insurance. It is important
to have this, as many districts will not contract with a company that
does not carry its own liability coverage. They may also ask for incor-
poration documents or other proof of the business. In some states,
once the company is approved, it does not necessarily mean that a
contract will be developed. Often, successfully completing the RFP
only means you are now vendorized by the district and are on their
approved list of providers. The SLP will need to continue to market
to individual districts or Special Education Directors to actually sign
a contract and provide services.

148  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Marketing is not difficult, and once the SLP has an appreciation
for the steps, as well as the process needed, then it is not hard to
find districts and obtain a contract. It does take persistence! Making
several calls per day is necessary for success. The SLPs that are suc-
cessful are not only persistent, but creative in their approach to the
decision-makers in districts.

Setting Up for Success
Once a contract is signed, there is still work that needs to be com-
pleted. The SLP must work with the district to ensure that all stake-
holders know that services will be provided during the school year. In
some states, this will require that parents/caregivers sign a document
stating that they understand what telepractice is and that they under-
stand the risks (e.g., cancelled sessions due to technical difficulty, the
possibility of personal health information being disclosed, and unau-
thorized users breaking into sessions). Each state is different about
whether or not signatures are required for this, so check state licens-
ing rules and regulations for each state. Principals at each school that
the SLP is serving should be contacted to introduce the SLP and
discuss the logistics of how the telepractice will work at their site. The
IT staff needs to be informed as well. Public schools have firewalls that
may need to be opened to allow a videoconferencing platform to be
used. They also have strict requirements about websites that can be
accessed. It is crucial to work with the district IT team to ensure that
the SLP will not have difficulty accessing the websites used for therapy.

During the contracting process, a conversation about the use of
eHelpers (see Chapter 4 for details) must be discussed. The SLP and
the Director need to determine who and what duties the eHelper will
perform. Most lower elementary-age school children will need an
adult to walk them to the computer and to be present if troubleshoot-
ing is needed. eHelpers can also assist with redirection of the students
as needed. If the district does not have a paraprofessional available
to serve this role, sometimes the duties can be divided among two or
more eHelpers, depending on availability. When the district does not

6.  Telepractice as a Business  149

have personnel available, it may be up to the contracting SLP to find
someone to fill this position. Using local college students, parents, or
other adults in the community may be a viable option. If this is not
acceptable, it is possible to set up a computer station in the back of
each classroom, or in a dedicated space in each classroom instead,
that is solely devoted to students with speech and language services
for their Individualized Education Plans (IEP). The SLP should then
work with the teachers on the best way to remind the students to go
to that computer for their therapy time. It is critical to work with the
classroom teachers to obtain buy-in for the services and to not place
additional burdens on them. These are things that can make or break
the success of a contract.

Grogan-Johnson (2018) noted that carrying out a needs assess-
ment will assist in the planning of telepractice services. The assessment
contains guiding questions in seven critical areas that include, “ . . .
infrastructure and equipment, personnel and training, the intervention
program, integration and collaboration with the school district, con-
tinuous improvement/program evaluation, funding/reimbursement/
cost of service delivery, and safeguards” (p. 21). This provides the SLP
with the foundational information necessary to implement a successful
teletherapy program. The needs assessment (Figure 6–2) can act as a
checklist in ensuring the teletherapy services are set up for success.

The needs assessment assists stakeholders in ensuring that the
setup is functional, that personnel are trained, and that there is a plan
for continuous improvement and evaluation. Tracking what works
and what does not allows the SLP to make corrections to the program
along the way in order to best serve the students. Going through the
needs assessment during the contract process will promote a success-
ful teletherapy program.

Choosing technology for a school setting that best suits the stu-
dents’ needs will facilitate participation in therapy sessions. Taking
into consideration the students’ physical, behavioral, cognitive, and
communication abilities will also help with determining the best space
for teletherapy to take place. A quiet room or space, with minimal
auditory and visual distractions, will support quality services. Deter-
mining the need for peripherals, such as external cameras and micro-
phones, will facilitate the student’s ability to actively participate.

Category Needs Challenges Associated Solutions
Cost?

Infrastructure & Equipment

1. What room/space is available
for telepractice services at
SLP and student locations?

2. Are the room characteristics
adequate at each site?
(Consider: door/privacy,
phone connection, sufficient
electrical outlets, adequate
lighting, room acoustics,
handicap accessibility,
proximity to printer, scanner,
fax machine)

3. What equipment is needed?
(May include: dedicated vid-
eoconferencing equipment,
computer, wide-screen
monitor, Web camera,
document camera, headsets,
microphone, audio splitter,
scanner, printer, fax, tele-
phone, desk, table, chairs)

4. What equipment is already
available?

5. Do you have adequate
Internet access? (Consider:
available bandwidth during
peak usage, potential need
to reconfigure firewalls to
allow telepractice, availabil-
ity of hard wired vs. wireless
access)

Personnel & Training

1. Do you have SLP(s) with
required state credentials?

2. Do you have a parapro-
fessional to assist at the
student site?

Figure 6–2.  School-based telepractice needs assessment. Based on S., Crutchley,
C. Dudding, S. Grogan-Johnson, & R. Alvares. (November 2010). From Telepractice in
Speech-Language Pathology (pp. 317–322) by K. Todd Houston. Copyright © 2014
Plural Publishing. All rights reserved.  continues

150

Category Needs Challenges Associated Solutions
Cost?

Personnel & Training  continued

3. Define the roles and
responsibilities for the
SLP and the assistant in
telepractice.

4. How will these roles and
responsibilities be com-
municated to the SLP and
assistant?

5. How will you train the
SLP and assistant on
correct use and trouble-
shooting of telepractice
equipment?

6. Is there CE available to
provide the SLP with skills
needed to be successful in
providing telepractice?

7. Are IT personnel available
for initial set up and ongoing
support at both sites?

8. Who will supervise the
paraprofessional?

9. Will substitutes be trained
and available for the SLP
and the paraprofessional?

Intervention Program

1. How will you select your
clients?

2. How will you determine that
telepractice is suitable for
your clients?

3. What alternatives are
available if a client is
not able to participate in
telepractice?

4. How will you consider Least
Restrictive Environment?

5. Will your students be seen
individually or in groups?

Figure 6–2.  continues

151

Category Needs Challenges Associated Solutions
Cost?

Intervention Program  continued

6. Is the selected technology
adequate to support group
intervention? (Consider the
need for multiple headsets,
wideangle Web camera,
seating arrangements,
student distance from
microphone)

7. What student-related
services will be available?
(Consider IEP and MFE
meetings, parent meetings,
open house, team meet-
ings, CE)

8. How will you gather student
data (electronically vs.
physical data recording)?

9. Where will student data be
stored?

10. How will documentation
be completed? (Consider
access to district software
or online services)

11. What therapy materials are
needed? (Consider software,
online resources, permission
to scan and use copyrighted
therapy materials, books,
materials for use with a
document camera)

12. What is the procedure
for troubleshooting and
assistance with technology
glitches?

Integration & Collaboration

1. Do you have support from
the building principal,
special education director,
IT coordinator, and other
district decision makers?

Figure 6–2.  continues

152

Category Needs Challenges Associated Solutions
Cost?

Integration & Collaboration  continued

2. How will you introduce the
project to faculty, parents,
and students?

3. How will you integrate the
project with other services
in the district?

4. What mechanisms are in
place to provide ongoing
communication to parents
and faculty regarding
student progress?

5. How will you establish col-
laborative relationships with
general education teachers?

6. What mechanism is in place
to respond to parent and
faculty concerns?

7. How will you integrate your
services with the general
curriculum?

8. What is the role of the SLP
and the paraprofessional in
communicating with faculty
and parents?

9. Have you identified and con-
sidered cultural and/or diver-
sity issues? (Consider tradi-
tional practices, idiosyncratic
words, views on technology)

Continuous Improvement/Evaluation

1. How will you measure
faculty, parent, and student
satisfaction?

2. How will you measure
student success?

3. How will you be aware of
new advances in teleprac-
tice technology?

4. How will you measure
reliability of technology?

Figure 6–2.  continues

153

Category Needs Challenges Associated Solutions
Cost?

Funding/Reimbursement/Cost of Service Delivery

1. Will the service be provided
by a district employee or by
contracted services?

2. Who will purchase and
maintain the necessary
equipment?

3. Is Medicaid reimbursement
available?

4. Can the paraprofessional
accept additional school-​
related responsibilities in
addition to working with the
telepractice project?

5. Will a time study be
completed to determine
increased efficiency?

6. Are grants or donations avail-
able to help fund the program?

Safeguards

1. How will student data and
records be maintained?

2. Have you completed a
risk analysis to ensure
necessary HIPPA and IDEA
compliance?

3. Do you have a copy of
the district regulations
for maintaining student
confidentiality?

4. Do you need to develop
security and privacy
guidelines specifically for
this project?

5. How will you communicate
the privacy and security
guidelines to parents?

6. Are the security and privacy
guidelines included in the
training for the telepractice
SLP and paraprofessional?

Figure 6–2.  continued

154

6.  Telepractice as a Business  155

In choosing a teletherapy service delivery model, SLPs are bound
by the ASHA Code of Ethics (ASHA, 2016) that states that it should be
equivalent to in-person services. Training should be provided to the
SLP and the eHelper who are providing services. Educational training
of the teletherapy model, although growing at the university level, is
still not a part of the curriculum of every graduate level program, so it
is incumbent upon the business owner to provide this training to their
staff. Many SLPs have learned this training on their own during the
pandemic, but some schools bring in experts to provide this training.
To continue providing services via telepractice, obtaining continued
training and reading current research is imperative to continued
growth in this area. Training should be done by experienced, quality
trainers and include information about all aspects of this service
delivery model (Grogan-Johnson, 2018).

When deciding on intervention programs, as always, the SLPs
should determine client goals and needs first, then look at the evi-
dence for support of intervention programs that match client goals.
The SLP should take cultural and linguistic differences into consid-
eration, and should talk with families to ensure they are in support
of telepractice, and that they understand what it is and what it is not.
Prior to the start of therapy, decisions should be made regarding how
and where progress will be documented. The school district may have
some form of an electronic medical record (EMR) that is used in the
schools, and the SLP would need access to this and the IEP system
in order to enter progress reports, as well as to the annual IEP infor-
mation. If the school bills Medicaid, the SLP will also need access to
the system utilized for this. All this should be completed prior to the
start of therapy sessions.

As noted earlier, support from the building principal, IT team,
special education director, families, students, support personnel, and
other district decision makers is critical to success. How the program
is introduced to school staff will affect whether or not it is accepted.
Determining how telepractice will fit into the school day and how
it will be managed, and by whom, will also contribute to its success.
The SLP needs a mechanism to communicate with teachers and fam-
ilies. It may be that each teacher and family has a preferred contact,
whether by phone, e-mail, or other means. Establishing this early on,

156  Telepractice:  A Clinical Guide for Speech-Language Pathologists

and by using preferred methods, will increase the likelihood of quick
responses. Ensuring that teletherapy is seamlessly integrated into the
school culture, along with collaboration with stakeholders, contrib-
utes to a smooth start of any teletherapy services.

Most districts have the funds, or will find funds, to serve stu-
dents with special needs when there is no in-person SLP available.
The SLP business owner should set up, in advance, how they will
invoice the district, when they will get paid, and the hourly rate that
will be charged to the district. If the district uses Medicaid, this may
also be a source of funding for these services.

For a business owner, tracking and measuring student success,
parent/caregiver and student satisfaction, and school staff satisfaction
is critical to continuous improvement. If the business owner knows
where there are problems, it is much easier to fix them going forward.
Often, by tracking satisfaction on a regular basis, the owner can inter-
vene when there is a hint of dissatisfaction and make every attempt
to fix an issue.

Safety of Clients
Finally, ensure that student data records are safeguarded, whether they
are kept on paper or stored electronically. Participation in a risk anal-
ysis ensures that compliance with HIPAA and the Federal Education
Rights and Privacy Act (FERPA) are met. Developing security and pro-
cedural safeguards for student records will certify compliance with
the legal responsibilities for operating a teletherapy program. Chapter 7
contains more information regarding legal and regulatory responsibilities.

Open communication is the key to maintaining good relation-
ships with school districts and will likely ensure that a contract will
be developed for subsequent years. Good communication will better
enable the SLP to correct any errors or missteps quickly. This leads
to trust, and the subsequent potential for Directors to refer the SLP
to other districts. As SLPs, we are taught clinical decision-making
processes and the critical thinking skills that we can use as a business
owner. Using these skills will go far in helping to establish a business

6.  Telepractice as a Business  157

that is quick to pivot when there are issues, and help them to continue
to grow as large as they would like.

Starting a business is relatively easy. Keeping it running and
maintaining a good reputation is harder. However, being prepared
for teletherapy and the problems that it could bring will set the owner
up for success. Asking good questions prior to the start of a contract
can help avoid the pitfalls that could potentially challenge a business’s
viability. Obtaining the knowledge and skills to effectively run a busi-
ness, as well as knowing how to handle issues with aplomb, will take
the SLP business owner a long way toward success, in whatever ways
they have defined what that success looks like.

References
American Speech-Language-Hearing Association (ASHA). (2016).

Code of ethics. https://www.asha.org/policy/et2016-00342/
Glaser, R. G., & Traynor, R. M. (2008). Strategic practice management

(pp. 39–71). Plural Publishing.
Green, S. A. (2016). I’d rather have a root canal than do cold calling!

SuccessWorks Publishing.
Grogan-Johnson, S. (2018). Getting started in school-based speech-

language pathology telepractice. Perspective of the ASHA Special
Interest Groups, 3(2), 21–31.
Murray, C. (n.d.). Entrepreneurship, a resource for emerging entrepre-
neurs. https://www.bra-network.com/blog/2021/09/01/lessons-
learned-advice-from-experienced-entrepreneurs-for-n​ ew-business-
o​ wners
U.S. Small Business Administration (SBA). (n.d.). Calculate your startup
costs. https://www.sba.gov/business-guide/plan-your-business/
calculate-your-startup-costs#section-header-3
U.S. Small Business Administration (SBA). (n.d.). Write your business
plan. https://www.sba.gov/business-guide/plan-your-business/
write-your-business-plan



7 Confidentiality, Ethics,
and Legal/Regulatory
Issues in Telepractice

Introduction

As telepractice grows as a service delivery model, understanding
confidentiality, ethics, and regulatory issues becomes critical to
clients and SLPs. Protecting client information is essential in obtain-
ing client trust. Knowing what confidentiality encompasses, and what
the rules and regulations at the state and national levels consist of,
is critical, as these can sometimes conflict. Ethical considerations,
such as following the ASHA Code of Ethics and the State’s Licensure
Board codes of ethics (if this regulatory body has one), will keep SLPs
in good standing legally and professionally. A Code of Ethics sets
out a framework of principles and standards that guide SLPs in the
day-to-day decision-making related to professional conduct (ASHA,
2016). State and federal laws guide us in the legalities of our profes-
sion. Laws will vary from state to state, and where there is a conflict
between state regulations/laws and the Code of Ethics, the SLP should
follow state laws. Federal laws are applicable in all states and must be
followed. These regulations include the Health Insurance Portability
and Accountability Act (HIPAA), the Federal Education Rights and
Privacy Act (FERPA), Health Information Technology for Economic
and Clinical Health (HITECH), and Children’s Online Privacy and

159

160  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Protection Act (COPPA), among others, and are relative to providing
teletherapy services to clients. These laws and regulations can often
be confusing, but it is up to the SLP to ensure they understand and
follow the laws and regulations to avoid penalties and possible jail
time. As the laws and regulations are discussed, it will become evident
that the Code of Ethics (ASHA, 2016) sets a standard of behavior and
gives guidance on professional conduct, which supports following
laws and regulations.

Code of Ethics
As noted earlier, ASHA Code of Ethics (COE) gives SLPs a framework
of principles and standards of practice for SLPs and Audiologists. It
should go without saying that all the principles and rules contained
within the COE apply whether the provision of services is made at a
school site, hospital, home, or anywhere else. Telepractice is a service
delivery model that clients can accept or decline, and SLPs are bound
to consider the client’s perspective when determining the service
delivery model. Just as SLPs determine, in conjunction with clients
and families, the therapy goals, the decision for the place of service is
also a decision of the client’s team.

Cohn and Cason (2019) state that the ASHA COE, “com-
mands lawful practice in Principle of Ethics IV, Rule R: Individuals
shall comply with local, state and federal laws and regulations appli-
cable to professional practice, research ethics, and the responsible
conduct of research” (p. 704). In addition, Principle I, Rule N con-
nects legal practice to telepractice by permitting it when it is not
solely completed via correspondence and is within professional stan-
dards and federal and state regulations. ASHA COE also contains
rules about committing fraud, being dishonest, causing physical
harm, or even threatening an individual. These rules are contain-
ed within Principle III, Rule D and, Principle IV Rule E (ASHA
COE, 2016).

Although the entire COE applies to all Certificate of Clinical
Competence (CCC) holders, no matter their setting, there are a few

7.  Confidentiality, Ethics, and Legal/Regulatory Issues in Telepractice  161

rules within the COE that apply directly to telepractice and should
be of note to telepractitioners, as they relate to state and federal reg-
ulations. Principle I, Rule H pertains to obtaining informed consent
from persons served, and the nature and the potential risk of services
provided and technology employed. When the teletherapy model is
used, certain technologies, such as videoconferencing platforms, are
employed for services. The COE requires our profession to inform
our clients, and their families or caregivers, of the teletherapy video-
conferencing platforms’ potential to fail or possibly be hacked. There
are some related state and federal laws about confidentiality, and SLPs
must check state regulations, as several states require signed consent
for teletherapy services. In addition, both HIPAA and FERPA address
confidentiality and how this applies to SLPs in various settings. (More
about HIPAA and FERPA later in this chapter.)

Principle I, Rules O and P of the ASHA’s COE pertain to pro-
tecting the confidentiality and security of records of the professional
services that SLPs provide. Using electronic medical records (EMR)
systems should be protected from potential intrusion by hackers or
anyone who should not have access to this information. Protecting
client confidentiality, whether online, in-person, or via medical or
clinical records, is of the utmost importance. Principle II, Rules G and
H address the use of technology. Practitioners are pressed to use tech-
nology (and instrumentation) consistent with accepted professional
guidelines and that the technology is in working order. If the technol-
ogy is not working, SLPs should not provide services until the tech-
nology is improved or fixed. During the beginning of the pandemic,
when everyone was scrambling to provide teletherapy, Internet speeds
and computers were not checked to determine whether teletherapy
was feasible. This may have resulted in poor quality services, which
goes against the notion that teletherapy services should be equal in
quality to in-person services.

Adhering to the ASHA’s COE gives SLPs the framework nec-
essary to provide ethical, high-quality services. As an SLP begins
teletherapy services, knowing and understanding the COE assists
in placing them on a sound footing for following the COE. It cer-
tainly helps to ensure that state and federal rules are followed. This
framework is for the benefit of the profession and helps to adhere to

162  Telepractice:  A Clinical Guide for Speech-Language Pathologists

regulations in each state. The COE supports day-to-day decisions and
keeps SLPs’ conduct professional. When questions about professional
conduct arise, these Principles and Rules offer us guideposts to live
by every day. They will facilitate keeping professionals in good stead
both within and outside the profession. Providing teletherapy ser-
vices outside of the United States will require the SLP to research the
regulations for each country, and in some cases, either be licensed/
credentialed in that country or, receive permission from the regula-
tory body in each country of practice.

State Regulations
Within the United States’ 50 states, there are 50 different sets of licen-
sure laws. Whereas many of the rules and regulations enacted have
similarities in terms of qualifications for licensure, they vary when it
comes to addressing teletherapy. Some states do not have rules or reg-
ulations specific to telepractice. Some states have a simple statement
indicating telepractice is an acceptable service delivery model, and
several states have definite rules and laws regulating teletherapy. It is
up to each clinician to read and understand the laws in their home
state and in each state where they provide service. States may have
conflicting rules or regulations. Again, it is up to SLPs to determine
which states’ rules and regulations prevail. Sometimes a licensing
board will determine that the client’s state rules are the ones that
prevail; yet others say something different. It is imperative to keep
abreast of the changing rules and regulations in all the states in which
the SLP provides services. During the pandemic, ASHA has done
an excellent job of tracking the changing rules during health care
emergencies (ASHA, 2021). Because the emergency orders are being
rescinded in some states, the rules and regulations are returning to
those that were in place previously.

Before initiating services, SLPs need to verify licensure require-
ments and regulations regarding telepractice in the state where the
clinician provides the service and the state in which the client receives
those services (ASHA, n.d.). ASHA states that the client’s location

7.  Confidentiality, Ethics, and Legal/Regulatory Issues in Telepractice  163

determines the site of service and goes on to assert that telepracti-
tioners “must be licensed in both the state from which they provide
services and the state where the client is located at the time of service”
(ASHA, n.d.). The same licensing rules may not bind employees of
the Department of Defense and Veterans Affairs. They should check
with their respective agencies to confirm licensure for telepractice.
As a side note, if a school-based SLP is providing teletherapy services
(as many did during the pandemic) they may not be bound by state
licensure regulations if they do not hold a state license. Check with
the state’s Department of Education for instructions.

SLPs, who provide services in additional states beyond their
home state, should keep abreast of telepractice regulations in all the
states they serve. As part of ASHA’s COE and state regulations, it is
critical to keep up to date. The COE states we must know and under-
stand licensure regulations and know of any changes that happen.
Check regulations for changes regularly and track these. It is the clini-
cian’s responsibility to learn rules and regulations and to follow them.
Living in a mobile society, clinicians must ensure their clients are in
the expected location. At the beginning of each teletherapy session,
it is incumbent on the SLP to ask the client where they are located,
mainly if it appears they are in a different location. SLPs should avoid
practice in states where they are not licensed. Clients and their fami-
lies may move around for a variety of reasons (e.g., visits to relatives,
going to a second home, etc.) and the SLP should establish the loca-
tion of a client at the start of each session.

Licensure Compacts
Occupational licensure compacts have been in existence in the United
States for decades. A common example of a compact is a standard
driver’s license. A state-issued driver’s license provides consistent
rules that allow licensees to drive across state lines in other states.
Similarly, a professional licensure compact allows members to work in
other states through “privilege to practice policies” or to more easily
transfer their license to a new state. As part of the privilege to practice

164  Telepractice:  A Clinical Guide for Speech-Language Pathologists

provision, states have the option of charging a fee and requesting
licensees comply with state jurisprudence requirements.

The Audiology & Speech-Language Pathology Interstate Com-
pact (ASLP-IC) facilitates the interstate practice of audiology and
speech-language pathology while maintaining public protection. The
ASLP-IC compact follows the trends of national state board and mem-
bership associations, including physical therapy, nursing, emergency
medical services, and psychology in educating legislators on formu-
lating and passing licensure compacts to benefit their occupation.

The ASLP-IC
n is a cooperative agreement enacted into law by participating
states;
n becomes operational when 10 states enact ASLP-IC into law;
n ensures that participating states communicate and exchange
information including verification of licensure and disci-
plinary sanctions; and
n requires audiologists and speech-language pathologists who
wish to practice under the ASLP-IC to obtain a privilege to
practice in the participating states. (Council of State Govern-
ments, 2021).

Telepractice and Licensure Compacts
The ASLP-IC supports audiologists and speech-language pathologists
in several ways. First, the compact allows licensed audiologists and
speech-language pathologists to obtain a privilege to practice across
state lines without having to become licensed in additional ASLP-IC
member states. The compact also includes provisions for audiologists
and speech-language pathologists to provide services to underserved
or geographically isolated populations through telepractice. This
facilitates continuity of care when patients, clients, and/or students
relocate or travel to another compact state. There are several regula-

7.  Confidentiality, Ethics, and Legal/Regulatory Issues in Telepractice  165

tions and stipulations related to the compact regarding the concept
of a “home state.” To provide the services allowed by this compact,
the professional must hold a home-state license in a compact state.
This applies to all license holders, whether practicing in person or
via telepractice.

Telepractice Opportunities Related to the ASLP-IC

n Increased public access to audiology and speech-language
pathology services by providing for the mutual recognition of
other member state licenses;

n States have enhanced ability to protect the public’s health and
safety;

n Support spouses of relocating active duty military personnel;
n Enhanced investigative and disciplinary information between

member states;
n Allows for the use of telehealth technology to facilitate

increased access to audiology and speech-language pathology
services (Council of State Governments, 2021);
n Improves consumer protection across state lines;
n Increases access to care for patients, clients, and/or students;
n Facilitates continuity of care when patients, clients, and/or
students relocate or travel to another compact member state;
n Promotes cooperation between ASLP-IC member states on
interstate licensure and regulation requirements; and
n Ensures that audiologists and speech-language pathologists
have met acceptable standards of practice.

Once the compact is fully operational, SLPs will have the ability
to apply for the privilege to practice in-person or through telepractice
in ASLP-IC states. On the ASLP-IC website, benefits to the public
include improved continuity of care, portability for military spouses,
and increased access to SLP services. The takeaway from the compact
is that it is positive and helps facilitate the teletherapy model.

166  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Federal Legal and Regulatory Issues
There is an alphabet soup of regulations that apply to telepracti-
tioners. As with state regulations and laws, it is incumbent upon the
SLP to understand and follow them. These include HIPAA, HITECH,
FERPA, and COPPA, among others. Still, these are the crucial acts to
know and understand when providing telepractice services. These are
federal regulations, and an SLP can be fined and jailed (in some cases)
if these are not followed. Not knowing about them or not understand-
ing them is not an excuse for not following them.

HIPAA appears to be one of the more complex Federal laws to
comprehend. It contains security and privacy rules that practitioners
need to acquaint themselves with in order to comply. The purpose
of this section is to familiarize the reader with HIPAA and its provi-
sions. This section does not purport to give legal advice. It is strongly
suggested when starting a private practice, whether in telepractice or
a brick-and-mortar office, that the SLP seek the advice of an attorney
with a background in HIPAA compliance.

Tomes (2012) notes that HIPAA protects not only medical
record health information, but financial, demographic, and lifestyle
information as well. Many of the HIPAA convictions involve financial
and demographic information (used for identity theft) rather than
health information. This type of data may be more at risk as opposed
to clinical data. Gaining knowledge of the Security and Privacy rules
of HIPAA will ensure that the SLP practice complies.

HIPAA defines “health information” as . . . any information,
whether oral or recorded in any form or medium, that is
created or received by a health care provider, health plan,
public health authority, employer, life insurer, school or
university, or health care clearinghouse; and relates to past,
present, or future physical or mental health or condition of
an individual, the provision of health care to an individual, or
the past, present, or future payment for the provision of health
care to an individual. (Tomes, 2012, p. 22)

7.  Confidentiality, Ethics, and Legal/Regulatory Issues in Telepractice  167

It is interesting to note that the definition includes schools.
Unfortunately, not all schools are aware that the information they
obtain for their special needs students contained in an IEP may be
covered by HIPAA. Again, there are differing opinions on this topic,
and it is best to contact a school district’s legal team for their opinion
on the health information contained in an IEP.

An SLP must first determine whether or not they are a covered
entity under HIPAA. Although SLPs are considered health care pro-
viders, to be a covered entity, the provider that transmits transactions
covered information in an electronic format are considered covered
entities. Most practitioners read this part of the regulation to mean
that the SLP must bill electronically to be a covered entity. However,
although this may be true, if an SLP sends one or more of the standard
transactions in electronic format, they are a covered entity. A transac-
tion is considered the exchange of information between two parties
to “carry out financial or administrative activities related to health
care” (Tomes, 2012) under any of the standard transactions under
HIPAA. Using an electronic EMR does not make a practice a covered
entity unless the EMR performs billing functions. If the SLP hires
a billing agency to do their insurance billing, the practice becomes a
covered entity because the billing agency functions as the agent of the
practice. In addition, if the SLP is considered a business associate of
a covered entity, mainly if they are doing something on behalf of that
covered entity, then that SLP becomes a covered entity. The impor-
tance of understanding all the intricacies of HIPAA becomes evident
as one dives into the law. If there is any doubt in the mind of the
SLP, then consultation with a lawyer or entity is necessary to ensure
compliance.

The Security Rule that is part of HIPAA will apply to any practice
that is a covered entity. This rule applies to all electronic health care
data that is stored or transmitted over any network. Any of this data is
protected, and the practice must follow these rules. Under the general
provisions of the Security Rule, the SLP must ensure the confiden-
tiality and integrity of the Electronic Personal Health Information
(EPHI) and protect it against any credible threat or breach. This
applies to both internal and external communications of the practice.

168  Telepractice:  A Clinical Guide for Speech-Language Pathologists

The Security Rule has standards, and each entity must specify
how they will meet those standards, and whether the standard is rel-
evant to the practice. If it is not applicable, it must be documented
why it would not be appropriate to implement that standard. The
practice should implement an alternative measure to address the
proper standard.

The Administrative Safeguards list of standards should be
addressed. A risk analysis is an essential part of HIPAA and must be
completed before providing services. It reduces risks and addresses
any vulnerability in the system. Specific sanctions should be in place
for any member of the practice’s staff who don’t comply with the secu-
rity policies. A security official that is responsible for the development
and implementation of the guidelines should be assigned. For a solo
practitioner, this would be the SLP-owner. The owner must develop
policies about who will have access to EPHI and when. All of this
information goes into a policy and procedure manual. Information
about how breaches will be reported to both appropriate government
agencies and clients should be included in the HIPAA portion of the
practice’s policy manual.

Often, SLPs will discuss purchasing a teletherapy platform (or
videoconferencing platform) that offers a B.A.A. (Business Associate
Agreement) which lays out which entity is responsible for what types
of breaches. SLPs should also have a B.A.A. in place for anyone or any
agency with access to the businesses’ EPHI, such as a billing agency, a
virtual assistant, and so forth. Entering into a B.A.A. on all sides will
go far in ensuring that HIPAA standards are being met.

There are numerous other rules and regulations contained
within the HIPPA law. It is not the purpose of this chapter to go in
depth into each of these, but to alert SLPs regarding the complexities
of the law and how it might apply to their practice.

As a part of HIPAA, it is essential to provide some information
about HITECH. The HITECH Act was created in 2009 to stimulate
the adoption of electronic health records. Around 2011, mandatory
penalties were imposed for non-compliance with this law. The high-
lights of HITECH include setting data breach notifications. Covered
entities were required to self-report any breaches to the Department
of Health and Human Services (HHS) when more than 500 patients

7.  Confidentiality, Ethics, and Legal/Regulatory Issues in Telepractice  169

were impacted. It also provided individuals the right to their Private
Health Information (PHI) in an electronic format, and providers
should be prepared for these requests. They can be fined for not pro-
viding them.

Business Associates (B.A.) and Business Associate Agreements
(B.A.A.) were established under the HITECH act. Business Associates
are individuals or groups who have access to the platform such as an
IT team. A Business Associate Agreement is a legal document that
lays out who is responsible for breaches in the platform. The B.A.
must share joint responsibility with a covered entity for any breaches
or misuse of information. The Business Associates of covered entities
must also report security breaches and are subject to civil and crim-
inal penalties.

FERPA is the law that protects the privacy of student records.
The question most frequently asked is how do FERPA and HIPAA
interact? It makes compliance with HIPAA more complicated for
those in educational settings because it has to be determined which
law applies to the records they are working with: HIPAA or FERPA.
To be clear, FERPA protects student educational records, which, at
the elementary and secondary level, would include student health
records, special education records (e.g., IEPs), and disciplinary
actions. The FERPA law gives parents specific rights with respect
to their children’s educational records, and with those rights being
transferred to the student when they reach the age of 18 years. Any
educational agency or institution that receives funds administered by
the U.S. Department of Education is subject to this law. This rule also
applies to some private schools.

According to Tomes (2012), whether or not a school is subject to
HIPAA is not a simple question. He notes that a school health clinic
would almost certainly qualify under HIPAA as a health care pro-
vider. Even if the school or clinic qualifies as a covered entity, it may
not have to comply with the Privacy Rule because that rule exempts
FERPA education records. However, imagine the example of when a
school uses a provider that does not work for the school (such as an
independent contractor) and that person provides services directly
to students. In that case, the records are not “education records” so
not subject to FERPA, but they are subject to HIPAA regulations.

170  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Again, talking with a HIPAA compliance professional will inform the
SLP as to who may contract with schools for services, and which law
applies—either HIPAA or FERPA.

Questions regarding whether group therapy is permissible under
HIPAA arise in both school and clinic settings. Others in a group may
hear private health information disclosed and may understand not
to take that information outside of the group. Or they may inadver-
tently or blatantly expose confidential health information to others
outside of the group. When working with group therapy, it is criti-
cal to have all members and families/guardians sign a consent form
to be in group therapy. The agreement should state that clients may
disclose personal information in the group and consent that what is
said in the group stays in the group. This consent should include a
warning that although the group agrees to keep any disclosed infor-
mation within the group, the practice cannot guarantee that a group
member will not share that information. The agreement should also
note that if group members disclose private information to anyone
outside the group, it may disqualify them from participating. It should
be noted that there are some exceptions in HIPAA that would allow
for group therapy.

COPPA is the Children’s Online Privacy Protection Act, and
whereas it may not directly impact client confidentiality or their
records, it affects the websites we may choose to use with our clients.
COPPA imposes specific requirements on operators of websites or
online services that are directed at children under 13-years-of-age,
and who are collecting that personal information online. This law sets
a framework of fair information practices governing the collection,
access to, and use of personal information collected on some of these
sites. The owners of these sites must post a clear and detailed privacy
policy that includes the names and addresses of the site operators, the
type of information they are collecting from children, and whether it’s
being disclosed to third parties.

Although COPPA regulations may not apply directly during a
therapy session because the SLP is the one logging into the websites,
if the SLP assigns homework to the student that includes logging into
a website, it is vital to educate (or alert) the parent/guardian regarding
COPPA regulations and confirm that they consent to their child’s use
of the website.

7.  Confidentiality, Ethics, and Legal/Regulatory Issues in Telepractice  171

Certified SLPs have a duty of care to follow the ASHA Code of
Ethics, as well as state and federal laws and regulations that protect
their clients’ confidentiality. Gaining knowledge about HIPAA,
FERPA, HITECH, and COPPA helps the SLP develop a policy and
procedure manual that follows both the state and federal government
laws. The reason behind these laws and regulations is to maintain our
clients’ confidentiality and protect this information from getting into
the wrong hands.

There are other ways to help ensure confidentiality and privacy
during teletherapy sessions. The SLP should ensure that only autho-
rized parties enter the online therapy room. Many videoconferencing
platforms offer password protection or virtual waiting rooms to help
ensure that no unauthorized individuals enter the virtual room. To
avoid unauthorized parties in the room with the client, the SLP should
inquire at the beginning of every session whether or not there are
others in the room with the client besides authorized family members,
or eHelpers in the case of a school setting. SLPs should consider how
they will maintain the confidentiality of any work created by the client
during a session. If there is a paper and pencil task, how will that get
sent to the SLP? Will it be scanned and sent in a secure e-mail, or will
it be sent via the postal service? Where will the information be stored
once it reaches the SLP? All these questions need to be considered as
systems are set up to handle confidentiality for each and every client.

With planning and thought, the SLP can establish policies and
procedures that ensure a client’s information remains private. There
are many resources available to assist with this process. The Office
of Civil Rights (Department of Health and Human Services) has free
information that is a good starting point for any practice. As noted
previously, consulting with compliance professionals may be an excel-
lent next step to keep the practice in good standing to ensure privacy
and protection of electronic information for their clients.

References
Audiology & Speech-Language Pathology Interstate Compact (ASLP-

IC). (n.d.). https://aslpcompact.com/

172  Telepractice:  A Clinical Guide for Speech-Language Pathologists

American Speech-Language-Hearing Association (ASHA). (n.d.).
Practice portal, professional issues, telepractice. https://www.asha​
.org/practice-portal/professional-issues/telepractice/#collapse_1

American Speech-Language-Hearing Association (ASHA). (2016).
Code of ethics. https://www.asha.org/policy/et2016-00342/

American Speech-Language-Hearing Association (ASHA). (2021).
State by state tracking of state laws and regulations for telepractice
and licensure policy. https://www.asha.org/siteassets/uploaded​
files/state-telepractice-policy-covid-tracking.pdf

American Speech-Language-Hearing Association (ASHA). (2021).
Tracking of state laws and regulations for school-based telepractice.
https://www.asha.org/siteassets/uploadedfiles/state-laws-and-
regulations-for-school-based-telepractice.pdf

Cohn, E. R., & Cason, J. (2019). Ethical considerations for client-​
centered telepractice. Perspectives of the ASHA Special Interest
Groups, 4, 704–711.

Council of State Governments. (2021). Audiology and speech-language
pathology interstate compact. https://aslpcompact.com/

Office of Civil Rights, Health and Human Services. (n.d.). https://
www.hhs.gov/hipaa/for-professionals/compliance-enforcement/
index.html

Tomes, J. P. (2012). Have you heard about HIPAA? A practical HIPAA
compliance guide for audiologists and speech pathologists. Veterans
Press.

Index

Note:  Page numbers in bold reference non-text material.

A Client candidacy, 26–27, 42, 45–49
Code of ethics (COE), 16, 155,
Absenteeism, 27
Adult clients, 4, 41 159–163
Aphasia, 4, 41, 123–127 Compensation calculator, 138
Apps, 49–55 Computer equipment, 16–18
Coronavirus (COVID-19)
checklist for determining viability,
54 implications, 1, 8–13, 26–27
Cultural considerations, 49, 55–60
Artificial intelligence, 29–31 Cultural humility, 55–57
Assessments, 82–94. Cultural responsiveness, 57

bilingual clients, 91 D
checklist, 92
preassessment checklist, 88 Dysphagia, 5–6
setup, 84–87
Audiology speech-language E

pathology interstate compact e-Helper, 7, 67–82
(ASLP-IC). See Licensure role in telepractice, 69
compact training, 81–82
Augmentative and alternative
communication (AAC). See Equipment, 16–22, 84–87
Tele-AAC Evaluations. See Assessments
Evidence-based practice (EBP),
B
51–55
Blended learning, 23–25 Evidence-maps, 43–45
Business plan, 133–137
F
lean startup, 134
Face–to–face, 23. See also In-person
C Facilitator, 4. See also e-Helper
Federal education rights and privacy
Cameras, 17–20. See also Webcams
Case scenarios, 101–129 act (FERPA), 21, 156, 159, 161,
Children’s online privacy and 166, 169–171
Federal guidelines, 166–171
protection act (COPPA),
159–160, 170–171

173

174  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Fees, 138. See also Rates P
Future directions, 27–30
Pandemic. See COVID-19
G Parent coaching, 79–81
Physical considerations, 46–47
Goals and objectives, 103, 117, 121, 124
R
H
Rates, 137–140. See also Fees
Head and neck cancer (HNC), 5 Report writing, 94–96
Headsets, 18–19
Health information technology for S

economic and clinical health Safety, 156–157
(HITECH), 159, 166, 168–171 School setting
Health insurance portability and
accountability act (HIPAA), marketing, 139, 142–148
21, 53, 70, 133, 156, 159, 161, needs assessment, 150–154
166–171 Sensory considerations, 46
History, 2–6 Service delivery, 22–27
blended, 23–25
I decision-making framework, 52
face–to–face, 23
In-person, 10–11, 23, 37–38. See also hybrid, 24–25, 27, 143
Face-to-face models, 23 38 39
telepractice model, 25, 37, 39
Internet speeds, 15–17 Speech recognition, 31–33
model, 32
L Speeds (videoconferencing), 17
State regulations, 162–163
Language sampling, 91–93
Licensure compact, 163–165 T
Linguistic considerations, 55–57,
Tele-AAC, 40
59–60 Telecommunications, 7–8
Telehealth, 6
M Telemedicine, 6–7
Telepractice model, 39
Marketing, 136, 140–148 Telepractice preparation quicklist,
Materials. See Therapy materials
Models of service delivery, 37-60 12
Terminology, 6–8
in-person model, 38 Therapy materials, 105, 118, 122,
telepractice model, 39
125–126
O Tips for connection, 33–35
Traumatic brain injury (TBI), 41–42
Observations, 93–94

Index  175

W V

Webcams, 17–20. See also Cameras Veterans Affairs (VA), 2, 41
Websites, 49–55 Videoconferencing, 3, 20–22

checklist for determining viability, platforms, 17
54 speed, 17