Organize your tasks visually with this easy-to-use Kanban board!
This tool helps you manage your workflow by moving tasks through “To Do”, “In Progress”, and “Done” columns. It runs directly in your web browser and saves your data locally, making it a simple, private way to stay organized.
Key Features:
Visual Workflow: Classic Kanban layout with “To Do”, “In Progress”, and “Done” columns.
Drag & Drop: Easily move tasks between columns using your mouse or touchscreen.
Custom Categories: Add your own categories (e.g., “Project X”, “Follow Up”, “Home”) to better organize tasks. Predefined categories include “Work”, “Personal”, and “Urgent”.
Color Coding: Tasks automatically change color based on their column (“To Do”, “In Progress”, “Done”) for quick visual status checks. Category badges also have distinct colors.
Confetti Fun!: Get a burst of confetti whenever you move a task to the “Done” column. 🎉
Local Storage: Your tasks and custom categories are saved directly in your browser, so they’ll be there when you reopen the app on the same device and browser.
Clear Completed Tasks: Easily clear all tasks from the “Done” column with a dedicated button.
How to Download and Use:
Download:
Click the download link provided
The license terms (GPLv3) are detailed below and available on the blog post/GNU website.
Open: Double-click the downloaded .html file. It will open in your default web browser. No internet connection is needed after opening.
Add Tasks: Type a task description, select a category from the dropdown, and click “Add Task” or press Enter.
Add Categories: Type a new category name in the “Add New Category” section and click “Add Category”. It will now appear in the dropdown list for tasks.
Move Tasks: Click and drag (or tap and drag) tasks between the columns.
Clear Done: Click the “Clear Done” button in the header of the “Done” column to remove all completed tasks.
Important Notes:
Local Data Storage: Task and category data is saved only in the browser you are currently using on this specific device. It will not sync automatically across different computers, tablets, phones, or even different web browsers (like Chrome vs. Firefox) on the same device.
Updates: For the latest version of this tool, please check the Nixon Speech and Language Blog or our Discord Community. Follow our blog or social media channels (linked below) for update announcements.
License:
This program is free software distributed under the terms of the GNU General Public License Version 3 (GPLv3). Essentially, this license guarantees you the freedom to use, study, share, and improve the software. You can redistribute it and/or modify it under the terms of this license.
Key points to understand:
Freedom: You are free to use, modify, and share this software.
Sharing Changes: If you modify the software and distribute your version, you must also license your modified version under the GPLv3 and make the source code available. You cannot make a modified version proprietary (closed-source).
Commercial Use: You can charge a fee for distributing copies or offering support/warranty for the software, provided you follow all GPLv3 terms (like providing the source code and keeping it under the GPL).
NO WARRANTY: This software is provided “AS IS” without any warranty. Nixon Speech and Language, LLC is not liable for any issues or damages arising from the use or modification of this software by others, as detailed in the full license text.
Brand Protection: The GPL license applies to the code. The Nixon Speech and Language name and logo are trademarks and are not automatically licensed for use by the GPL.
The full terms can be viewed on the GNU GPL website. Please refer to the full text for complete details.
GNU GENERAL PUBLIC LICENSE
Version 3, 29 June 2007
Copyright (C) 2007 Free Software Foundation, Inc.
Everyone is permitted to copy and distribute verbatim copies
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reviewing courts shall apply local law that most closely approximates
an absolute waiver of all civil liability in connection with the
Program, unless a warranty or assumption of liability accompanies a
copy of the Program in return for a fee.
Merriam-Webster includes the following in the definitions of progress:
“a forward or onward movement (as to an objective or to a goal) : ADVANCE”
“a gradual betterment especially: the progressive development of human kind”
“to move forward: PROCEED”
“to develop a higher, better, or more advanced stage”
Know history – diverse history. Use research to improve education and healthcare so we can move forward not backward. Image created by Dr. Nixon’s description provided to Adobe AI.
Imagine.
Pause. Imagine that it’s 1990. You are in a wheelchair. You do the same work as your peers, but you get paid less. You can’t go to a movie theater because there aren’t accessible seats.
Do we really want to go back to that?
That was life before the Americans with Disabilities Act of 1990 that includes Section 504. Section 504, the section being the one currently being challenged by attorneys general in 17 different states with Texas v. Becerra.
In an essay written in Time on February 19, 2025, Rebekah Taussig wrote:
“In many ways, Section 504 has operated as an almost invisible protection – easy to take for granted. And in doing so, we’ve been able to continue the fiction that disability is something that happens only to others. The undeniable fact is that every one of us will acquire a disability if we live long enough. Disability is an experience we can move in and out of over the course of our lives, and disabled people are the only minority group anyone can become a part of at any moment. Section 504 is not a law for “those people.” …
As with much of U.S. politics right now, Texas v Becerra feels like a reckless attempt to pull us back to a former time. But there is one crucial difference between 1977 and 2025. More than one generation of disabled children has grown up under the protections Section 504 provides us. And while the politicians are still reciting the same script, our revolutionary predecessors gave us a new story. We are a valuable part of our communities, we belong here, and we’ve been shown how to fight.”
It was because people were (and still are, just check Supreme Court Cases) treated differently based on their race, religion, national origin, (dis)ability, gender (and gender identity), and sexual orientation.
If you think that shouldn’t be a concern, just take a look at what Rep. Rich McCormick (R-Ga) said when asked about school lunches after Trump proposed a federal funding freeze that could affect nutrition support for children: “Before I was even 13 years old, I was picking berries in the field, before child labor laws that precluded that. I was a paperboy and when was I was in high school; I worked my entire way through”.
Use of the phrase “back in my day” to dismiss concerns
Just because something was one way in 1954, doesn’t mean it should continue – particularly when it comes to civil rights.
Disclaimer. This post is not medical or legal advice.
The information provided in this blog post is for educational and informational purposes only. It is based on historical research, analysis, and interpretation, which may be subject to varying perspectives and ongoing scholarly debate. While every effort has been made to ensure the accuracy of the information presented, I do not guarantee its completeness or infallibility. Historical accounts can be complex and nuanced, and my interpretations reflect my understanding of the available sources at the time of writing.
This blog post may also contain personal opinions and reflections on the historical events and figures discussed. These opinions are my own and do not necessarily represent the views of others. They are offered as a basis for discussion and further exploration of the topic.
Readers are encouraged to conduct their own research and consult multiple sources to form their own informed opinions. I am open to respectful discussion and feedback on the content of this blog post, and I acknowledge that historical understanding can evolve over time. Any errors or omissions brought to my attention will be considered and, where appropriate, corrected.
By reading this blog post, you acknowledge that you understand and agree to the terms of this disclaimer.
Many people talk about university researchers as living in the “ivory tower” unaware of the needs of people in society.
I challenge you to pause for about 10 minutes and watch this video courtesy of PBS News to better understand potential long-term impacts of Trump’s cuts to research funding.
(And yes, I know the video is about medical research funding, but the same applies to education. Also, NIH funds more than medication research. They fund research into child development, reading, language, speech production, and so much more.)
PBS News Hour clip about Trump’s cuts to medical research funding (2025). This is a wonderful summary.
Beyond that video, did you know that research grant funds also help pay tuition for students working in those labs? Yes. They can make higher education more affordable.
It’s part of the reason most grad and doctoral students look for labs with funding.
If research funding is decreased, then we may end up with less socioeconomic diversity in higher education due to the cost.
If research funding is decreased, then students who choose to pursue higher education degrees are likely to have higher student debt.
What can you do?
Contact your representative and senator
Speak UP! Post on social media!
Disclaimer. Information provided in this post by, Stephanie M. Nixon, Ph.D., CCC-SLP, is provided in good faith. Nixon Speech and Language, LLC makes no representation or warranty of any kind, express or implied regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any information supplied by other sources.
Information provided here is for informational purposes only.
If you don’t need this article to realize the necessity of the Institute of Education Sciences (IES) and their role in funding high quality independent educational grant research, then please sign this petition in an effort to halt actions by DOGE and the current Presidential administration: https://chng.it/vjdYGZw9wz
If you just need the numbers to sign the petition:
2024 entire Federal Budget was $6.75 trillion.
IES had an $807 million budget in 2024
Between $800 million and $1 billion in IES research grants were cut by DOGE (Grants are paid over multiple years. See the note below.)
Note. In this Washington Post Article posted 2/13/2025 by Meckler and Natanson, Nat Malkus, a senior fellow at American Enterprise Institute DOGE may have overstated the cost of the canceled contracts because many of the contractors were several years into the agreements, meaning the money has already been spent.
In other words, canceling the grants right now likely caused more waste, especially if the studies cannot be completed due to lack of funding.
Other reasons to sign:
IES is part of the accountability arm of the education system
Studies are being cut short including one called, ReSolve designed to help students learn math faster.
Federal funding cuts including grant funding to researchers at the institutions is devastating. This article in the GW Hatchet by Jenna Lee (2/11/2025) addresses lawsuits related to the NIH Federal funding cuts
DOGE cut additional resources within that funding including:
Common Core of Data, primary database of all K-12 schools with enrollment, demographics, and other information is collected
What Works Clearinghouse: a project that has been essential to facilitating decisions for administrators and educators (see below for more)
School Pulse Panel: began surveying K-12 public schools about education related topics
Studies about international education
Career and technical education
Early childhood education
Contact your congressmembers. Protect this funding so our country can move forward with improving our education system on the whole vs. backwards. We need independently funded research. It is paramount.
I posted this in a previous post, and I’m posting it again.
If you need more convincing or just want some background, then read on.
Briefly…why do we have a Federal Department of Education?
Before we can discuss the Institute of Education Sciences (IES), we need to consider, why do we have a Federal Department of Education (DoEd)? Can’t the states do everything?
Time machine:
Let’s hop in our “time machines” and review history:
Non-cabinet level agency with Henry Barnard as the first commissioner (and a staff of 3 and only 2 rooms)
Objectives:
improve American education by providing strong education information to local- and state-level authorities without having official control of the authorities in the states
collect statistics and facts to show educational progress across states and territories
Henry Barnard
He deserves his own post (if I have time). For now, review the Barnard Papers and the information from Cross and Islas. Barnard had to collect data from the schools and send it to practitioners. He and his small staff produced reports and research to help give a context for education.
July 20, 1868: Congress decided the the efforts by Barnard was a waste of national resources, reduced the funding, and then on June 30, 1869 removed the DoEd’s independent status and relabeled it the Office of Education with the Department of Interior.
1870:John Eaton served as the US Commissioner of Education until 1886 with only a $6000 yearly budget.
1889 to 1906: Commissioner William Torrey Harris continued the data collection and expanded it to include public and private elementary school enrollment.
This path continued, the name changed and shifted. In 1953, the Department of Health, Education, and Welfare. More funds were available due to political and social circumstances.
In 1963, President Lyndon B. Johnson emphasized the need for education to fight poverty leading to the Higher Education Act (1965) and Elementary and Secondary Education Act (1965).
Now, it’s 1979, President Jimmy Carter signed into law the Department of Education Act
This established the Federal Department of Education as a cabinet-level department.
What kind of funding did DoED receive in 2024?
Per USAfacts.org, DoED received 4% of all federal funding in 2024, totaling $268.35 billion.
Originally posted by USA FACTS.
DoEd is the smallest of any cabinet-level department with about 4,100 full-time employees (as of 2023).
What is/was the function of DoEd as of 2024?
Note. Given the unknowns related to what data/websites will remain available under the current administration, I cannot guarantee the existence of any links to federal websites. If you click a link and it is gone, then please contact me and I will do what I can to find the information and make it accessible (when possible).
“Strengthen the Federal commitment to assuring access to equal educational opportunity for every individual;
Supplement and complement the efforts of states, the local school systems and other instrumentalities of the states, the private sector, public and private nonprofit educational research institutions, community-based organizations, parents, and students to improve the quality of education;
Encourage the increased involvement of the public, parents, and students in Federal education programs;
Promote improvements in the quality and usefulness of education through Federally supported research, evaluation, and sharing of information;
Improve the coordination of Federal education programs;
Improve the management of Federal education activities; and
Increase the accountability of Federal education programs to the President, the Congress, and the public.”
As noted on the about page for DoEd, the mission “is to promote student achievement and preparation for global competitiveness by fostering educational excellence and ensuring equal access for students of all ages. Learn more about our mission, offices within ED, key initiatives, and more.”
What is the Institute of Education Sciences (IES)?
promotes high quality comprehensive research to expand knowledge of children and youth with or at risk for disabilities
age range is infancy through post-secondary education
ERIC: Repository of education related information including journal articles, dissertations, and other such resources
Importance of IES
IES is how we improve education. Under this institute, there have been education advances. Chester Finn wrote commentary on February 12, 2025 about this current situation with funding cuts to IES by DOGE. IES in its current form “corrected much of what was weak and wasteful in the previous arrangement —and the new agency got off to a strong start under the leadership of Grover (Russ) Whitehurst, who strove with considerable success to see that its work would be conducted as proper scientific research—controlled experiments, etc.—and data gathered and reported with objectivity and integrity”.
Information for this post was pulled from these webpages (citations also linked within the post itself as appropriate):
Disclaimer: Including these links is not intended as Nixon Speech and Language, LLC’s or my an endorsement OR agreement with information created by the authors, companies, institutes, or websites. If you find factually inaccurate information in my post or a link, then please let me know and I will adjust.
Disclosure. I am writing this as a supporter of strong education science and research. I am writing this as educators need rigorous peer-reviewed randomized studies to facilitate decisions. In my opinion, they also need access to quickly disseminated information as is available in What Works Clearinghouse. I am concerned at the likely negative outcomes for all children, but particularly those with learning disabilities or at risk for learning disabilities.
I worked at the Institute of Education Sciences from January 2004 through about March 2005 in the National Center for Education Research. I saw the amazing research. I watched the peer reviews.
Disclaimer. Information provided in this post by, Stephanie M. Nixon, Ph.D., CCC-SLP, is provided in good faith. Nixon Speech and Language, LLC makes no representation or warranty of any kind, express or implied regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any information.
The opinions expressed in this post, are exactly that, opinions of Stephanie M. Nixon, Ph.D., CCC-SLP.
Note. This is an updated version of an article I wrote in 2021 for Apraxia Kids. The main reference was to childhood apraxia of speech research, but this applies to research across the sciences.
Some current (2025) actions by the executive branch make information of utmost importance. Some changes threaten sources of independent research funding.
What is evidence-based practice?
You may have heard speech-language pathologists (SLPs) saying “evidence-based practices” when describing a specific treatment approach. Such practices are based on scientific evidence and professional experience while considering your child’s specific needs.
Scientific evidence is used by SLPs, educators, and medical professionals (among others) to guide interventions and strategies could help a person based on their specific needs.
There is not one approach that works for all people, especially not for all children with childhood apraxia of speech (CAS). There are some approaches that have not been studied at all or have been studied with research methods that don’t allow for very strong conclusions.
What is scientific evidence?
Scientific evidence is empirical data that is collected and interpreted using the scientific method. This is evidence that serves to support or counter a scientific theory or hypothesis and is derived from controlled studies.
Is all scientific evidence high quality?
Simply put, no.
Well-designed research studies are more valuable tools than an anecdotal opinion.
What are the levels of evidence?
Additional information about evidence-based interventions as defined in the Every Student Succeeds Act (ESSA) from the California Department of Education.
Let’s summarize…
The lowest form of evidence = opinions based on “experience”
Best form of evidence = pulling multiple randomized controlled trials into guidelines or a meta-analysis
Anecdotes are not evidence especially when these anecdotes are offered by (or on websites of) people/companies with a commercial interest.
Note. Researchers/organizations obtain grant funding by applying. Even then, there is a review process to determine whether they receive the funding.
Applications are peer reviewed by field experts who determine whether the application meets the criteria among other standards.Why does commercial interest matter in speech-language pathology or education?
What is a commercial interest? Earning money by selling a product OR saving money by not providing a service. (The latter is more relevant to health insurance – at least for now.)
Example: Dr. Blah at company XYZ creates and markets a program to teach math. If it is sold to school districts, then they will make money. Now if XYZ and Dr. Blah are the only ones who research the program they are more likely to determine this “works”.
What can decrease the quality of evidence?
Specific to CAS treatment research studies, look for study limitations (e.g., small sample size, inconsistent implementation of treatment approach, lack of a control group or condition, pre-treatment differences between groups, analysis performed by non-blinded outcome assessors, etc.).
Do we have much of the Level 1 standard research for Childhood Apraxia of Speech treatment?
No. We have a few meta-analysis studies and systematic reviews available.
Here are some systematic research reviews (most summaries by the American Speech Language Hearing Association in their Evidence Maps):
Murray, McCabe, and Ballard (2014) concluded that of the research articles they analyzed, at least 3 treatments had sufficient evidence for Phase III clinical trials. Those treatments were Dynamic Temporal and Tactile Cueing (DTTC), Integrated Phonological Awareness, and Rapid Syllable Transition Treatment.
Ng, McCabe, et al. (2022) found an evidence base for the use of Rapid Syllable Transition Treatment (ReST).
Springle, Breeden, et al. (2020) found limited higher dose and frequency of motor programming treatments appeared most effective for children with CAS.
SLPs can look at the “evidence” to determine which approaches are most likely to work. The evidence includes the research available and the patient’s unique needs.
What characterizes a strong treatment research study?
Diversity in the population? (i.e., Gender? Race? Ethnicity? Primary language? Age – depending? Diagnoses? Socioeconomic status (SES)? Geographic location? Gender identify and expression? Disability status?)
Why do we care about diversity in the sample ?
Simply put: Inclusivity matters. The linked 2023 article by Alice McCarthy details the need for inclusive clinical trials.
Yes, we’re dealing with speech-language therapy trials vs. drug trials; but, that doesn’t change the need to ensure a representative population. This might advise a research of possible barriers to care as well as how to address the barriers.
Randomization: There are many types of randomization as described in the article linked (Lim & In, 2019). Randomization helps researchers eliminate/minimize accidental bias (including selection bias).
e.g., We want to ensure that patients weren’t chosen to receive the “treatment” group merely because they seemed to have more or less speech sound errors.
Bias in research
Bias in research is beyond the scope of this article. If you’d like to learn more, here is one journal article by Pannucci and Wilkins (2010).
Internal consistency indicates that several items measuring the same idea generate similar responses.
External consistency is the degree to which results are consistent with prior research.
Specific to consistency of analysis, we want to know how reliable were measures of patient performance. What was the level of agreement between/among therapists? How about a novel therapist?
Were the control and treatment interventions provided as intended? For example, did the SLPs administering the interventions stay within the guidelines provided by the research study? Did they introduce any concepts not included in the study?
Was the same modality of treatment used across patients in each condition? (in-person, telehealth, etc.)
Example.
(1) SLP working with a child in the “control” group includes some of the techniques from the “treatment” being tested and child shows progress in the “control” intervention.
Does this mean the “control” intervention works? No. It means the SLP did not follow the research protocol in the “control” intervention.
(2) SLP working with a child in the “treatment” group includes techniques beyond those described by the researchers as part of the treatment program (e.g., visual aids, cues, etc.) and the child shows progress with the “treatment” intervention.
Does this mean the “treatment” intervention works? No. It means the SLP did not follow the research protocol in the “treatment” intervention.
Other important factors
We also need to consider the presence of other factors that could explain improvement or regression (including whether these were controlled in the study). and whether these are controlled (e.g., if a child also received treatment elsewhere, or if a child started school, or had a medical procedure).
Was the child receiving treatment beyond that supplied in the study?
Did the child start school while in the study?
Did the child experience any medical changes during the study? (e.g., new medication, surgical procedure, new diagnoses, accident, etc.)
Maturation(i.e., getting older) is another factor to consider when reviewing treatment studies. That is, did the treatment group improve beyond what would be expected based with aging.
What if one approach with research support isn’t working for my child?
Well, if you have that concern, ask the practitioner. Practitioners usually track progress so they know when they need to adjust intervention (i.e., when the approach is not effective for the patient or when the patient masters an objective, etc.).
As a clinician, I ask myself these questions when an approach doesn’t seem to be “working”?
How long have we tried the approach?
Am I implementing the approach correctly? (It helps to review the approach.)
Is the child engaged (i.e., attending) with us during our sessions?
How consistent is the child’s attendance?
Have we provided appropriate family education (if included) with the approach? (This includes home practice)
Sometimes an approach just isn’t the best option for a child (and their family) and we need to adapt. This could include modifying the approach slightly to adapt or even changing approaches to one more suited for the child.
Regardless, an approach should have an evidence base, even if it was only demonstrated in a “single-subject design case study”. This allows SLPs to generate ideas/hypotheses (sophisticated educated guesses) about what might work for a given child.
Disclaimer. Information provided in this post by, Stephanie M. Nixon, Ph.D., CCC-SLP, is provided in good faith. Nixon Speech and Language, LLC makes no representation or warranty of any kind, express or implied regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any information.
Information provided here is for informational purposes only.
This material is not substitute for professional medical advice or treatment. Always seek the advice of a qualified professional with any questions you may have regarding conditions and treatments/therapies. Do not delay seeking professional medical or educational advice/evaluation or delay seeking it because of something you read on this website.
See these websites for more information about evidence-based practices and research:
Stephanie M. Nixon, Ph.D., CCC-SLP January 29, 2025
The power of a name, label, or diagnosis – even the name of a symptom
What’s in a name? A label? A diagnosis? Does knowing a diagnosis grant us power? Does it provide the knowledge we desire when confronting a situation (not just learning disability or health-related)?
When I wrote about this years ago in my undergraduate thesis about Egyptian religion, I noted the similarity between naming gods and goddesses who “controlled” various aspects of life (love, weather, sun, rain, etc.) and naming hurricanes. I know this is over simplified in some ways, but there is a parallel.
“Sometimes naming a thing — giving it a name or discovering its name — helps one begin to understand it. Knowing the name of a thing and knowing what that thing is for gives me even more of a handle on it.” — Octavia E. Butler, Parable of the Sower
Thinking about what Octavia E. Butler said above, it makes sense (at least to me). It helps to just understand sometimes. And other times, it might bring a “fix”. Granted a often there isn’t a “fix” or “cure” for learning disabilities or chronic illnesses or even natural disasters. i.e., It’s not always just here, take this medication for 10 days and you’re all better. (I wish it was that easy…)
For ADHD and autism, there are no cures but there are treatments and there is understanding.
For chronic illnesses like my diagnosis of Hashimoto Thyroiditis, often there is no cure. You might need to take a medication daily depending on your doctor’s advice. Some chronic illnesses are even progressive. Some are merely described via symptoms, but we cannot “cure” it.
For natural disasters, we cannot stop the hurricane from hitting an area, but we can prepare for it. And we can provide disaster relief afterwards to help an area recover
What have I seen, personally and professionally?
As a practitioner, I sometimes patients/caregivers wanted a diagnosis and others wanted the descriptor and support. For adult and pediatric patients, a label can help with insurance coverage. For pediatric patients, a label (i.e., a diagnosis – even working diagnosis, e.g., autism, dyslexia, etc.) can help with access to special education services and accommodations and insurance coverage for services.
As a patient, adding the diagnosis of autism to my long-time diagnosis of ADHD helped me understand those feelings of overwhelm from too much noise, too many “things” coming at me, and much more. Has it “fixed” the situation? No. But it gives me grace in those moments or even afterwards when I can recognize the link to “autism”. (I recognize this won’t apply to everyone. Some people find hearing the actual diagnosis scary.)
What’s in a name?
When it comes to chronic illnesses (even acute), speech and language disorders, learning disabilities, autism, ADHD, and more, we as patients (and even practitioners) often want to know the diagnosis/name. We want to understand what we’re dealing with. But why?
Empowerment, knowing how to prepare, find options, and find ways to cope (social groups, etc.)
Validation, knowing what we feel/see is happening, someone else sees it
Understanding, understanding of ourselves and what we need and for parents of a child, understanding of a child’s needs
Forgiveness of ourselves (our children and loved ones where applicable), knowing a “diagnosis” can help a person recognize how the diagnosis affected a situation and forgive themselves or another for this. (I’m not saying a diagnosis is an excuse! I’m saying, it can give that allowance to make that mistake.)
Access, having a diagnosis or adequate symptom description can give access to accommodations, insurance coverage, and research studies that are otherwise unavailable. (e.g., For pediatric speech-language therapy, many private insurance plans have exclusions saying that services are only covered in cases of accident, injury, stroke, or autism spectrum disorder.)
What do many patients want?
As a patient, I want to be heard. I want to be validated. I am living this life, not the practitioner. I want that practitioner to treat me like I treated my patients, which is to listen, genuinely listen. Don’t discount what I’m telling you because you aren’t seeing it in this moment at this time.
When I saw patients, I tried to remember, treat them like I wanted to be treated. Yes, they may want the why, the cure, the fix, but I did my best to explain what I saw and next steps. And hear their responses and consider them in light of what I saw in that 2 hours in my office.
And of course there are times we may find nothing definite, but we can validate their experience. We can listen. We can recognize when there is something off that just may not be recognized by available tests.
There are many times that there isn’t an exact diagnosis. We can describe the symptoms and those might even have “diagnosis codes” in ICD-10, but we may never know the overarching “cause” for those symptoms or if there is one. BUT, even describing the symptoms and assigning ICD-10 codes provide a “name”.
Like many of my families and patients I have had over the years, I have navigated the waters of the unknown with my health and learning. I know how scary those waters can be. I know there isn’t always an answer, but my objective is to benefit others with my knowledge and experience. Even if it’s just how to navigate healthcare systems or health insurance or a diagnosis/symptom.
More recently, I decided to record some of my symptoms and post them to YouTube to share the journey with others. My hope is that professors, practitioners, and patients can benefit from these in some way.
Would I like to know a cause? A name? A diagnosis? Who wouldn’t? BUT – even if I can’t learn that information – if I can benefit others, then in my opinion I won.
Thoughts for providers
Providers, if you are frustrated by patients seeming “hung up” on getting that “label”, it’s for the reasons I said above. What can you do?
Respect the request – and try to understand
Sit in their shoes a minute
Ask the patient/family why they seem to “want” the diagnosis
Consider whether they experience something you may not see in your office
Use your active listening skills
Consider reviewing the data and scheduling a follow-up
Avoid assuming you know more about that patient than the patient/family (you only see them for that short period in your office)
Empower them to help you see what they see
Ask if there is an insurance reason they need a diagnosis
Consider whether the person could benefit at minimum from an acting diagnosis (if appropriate) to give them access to care that would otherwise be denied
Ask them how what they report is different than previous function (if appropriate)
Ask how it is affecting them in daily life
Tangent. Consider a patient’s background during the appointment
If that patient is an allied health professional trained in the area they are coming to you about, please pause and consider that this patient may be using every tool they know to minimize the effect of their concern in your office. Listen. Think about the tools they might have – objective tools (like a measure of grip strength for OTs) – that you don’t.
An example from many years ago
Over 10 months from 2010 and 2011, I went through over 20 rounds of antibiotics for respiratory infections before seeking a pulmonary doctor. Finally, I went in. My voice was hoarse from all the coughing. I told the doctor (who will remain nameless) that I was going to lose my voice. I asked for someway to help the cough so I wouldn’t lose my voice. (Try being an SLP with no voice.)
The doctor told me I wouldn’t lose my voice. I reminded her of my training. I reminded her of my specialty. I was dismissed. I was in tears trying to explain myself to her.
Fast-forward. The sputum culture returned. It was Methicillin Sensitive Staphylococcus Aureus. I was given an antibiotic. But due to coughing, I lost my voice 24 hours later. I did not regain enough voice to return to work for at least 3 weeks. (Even when I returned, I barely had enough voice to talk through the day.)
I saw an ENT who specialized in voice, who said I had an ulceration on my vocal folds from coughing.
To patients and practitioners
I understand the frustration from both sides. I’ve been there. I’m there right now. I know how scary the unknown is, but let’s work together. Let’s listen.
Practitioners, involve patients who want to understand when reviewing their case. Don’t hesitate to say “I don’t know” or “I need to go look that up”. Just be sure to get back to the patient later.
Patients/families, I know the information is sometimes overwhelming. Don’t hesitate to pause the practitioner, repeat what they said, and as if you understood. As for a list of action items. And tell the practitioner if you have any barriers to accomplishing those items (even time to make those phone calls). Find out how to contact your practitioner. You deserve someone who will listen and advocate for you.
So…again, what’s in a name, a label, a diagnosis? It can be more than a provider might know from access to understanding. Validating a symptom observed goes a long way, especially if that has an ICD-10 code – even if there is not treatment available. And that ICD-10 code is something researchers might look up in the system in the future and look at associated health conditions which could lead to better understanding and treatments.
Yes, that might be a long way off, but again, for someone like me who just wants to help others, I don’t care if it’s 100 years off. If my data helps practitioners and patients learn about health conditions, then I will view it as a win.
Disclaimer. This article is based on personal and professional experience as well as research on counseling patients. This information is not intended as legal advice or healthcare advice. Please see a provider about any healthcare needs. I acknowledge that some people need different approaches than others when receiving information, so again, providers use your informed clinical training and judgment.
A medical claim is a bill that your provider sends to your health insurer for your medical care (or if “out-of-network”, a claim you send to your health insurer). (This claim includes codes called CPT codes – or procedure codes – associated with the costs.)
A prior authorization (also called precertification) is when your health plan requires patients to get approval for a medical service or medication before they receive the care. Information from your chart must be submitted from your chart by your practitioner (and sometimes by you). (I will address PAs more in a later post.)
When I refer to denial in this post, it means denial of a code on a medical bill or denial of a prior authorization request.
But remember there is a difference. And you can sometimes prevent medical claim denial by confirming whether precertification or prior authorization is needed for a medical service.
For a medical claim, the medical service was already completed and the bill was filed with insurance. You could be stuck with the balance when there is a denial.
For a prior authorization, the provider is requesting that your health insurance company agree to pay for a medical service. The service has not been completed.
Note. As an SLP, a frequent reason that I saw claim denials and prior authorization denials by private health insurance companies for a child’s speech-language therapy services was the plan did not include “habilitative” services OR only included them for autism spectrum disorder. i.e., “This service is only covered in cases of accident, injury, stroke, or autism spectrum disorder”.
What I do. I often call to confirm coverage of any services I am going to receive (or when I was providing services to patients. I ask these questions: Are there any exclusions?Do I need prior authorization? If the answer is yes to either or both, I ask for additional information about these. I take notes. I write down the date, time, and name of the person on the phone. I put that information where I won’t lose it. (Take a picture, put it in the notes app on your phone, anything.)
What is downcoding during claims processing?
The health insurance company changes a higher-level CPT (i.e., procedure) code (e.g., CPT 99214 indicating moderate complexity over 30 minutes) to a lower-level CPT code (e.g., 99213 indicating low complexity 20 minutes).
No matter in- or out-of-network it results in lower reimbursement as the lower code is associated with a lower payment amount.
An example from one of my out-of-network claims where my health insurance company used downcoding for a CPT code.
Column A = Billed Amount Column B = Member Rate (nothing there because this is out-of-network) Column C = Not payable by plan Column D = Applied to deductible (I hit my out-of-network deductible early this year.) Column E = My copay (does not apply to out-of-network) Column F = Remaining amount (Amount billed – Notpayable) Column G = Plan’s share (For me, this was 75% of the amount they deemed appropriate after downcoding) Column H = My coinsurance (For me, this was 25% of the amount they deemed appropriate after downcoding) Column I = My total share (Coinsurance + Not payable by plan)
You (and your practitioner if they are in-network) must watch your explanation of benefits for downcoding. This isn’t something they will tell you with a phone call or an email. It appears with those numbers referencing the reason which is at the bottom of the bill.
So if you see those numbers, look for a reason. If you are struggling to read the explanation of benefits, then ask a biller at your hospital, the specialist, or you could even email me.
Health insurance companies will say they do this to prevent upcoding by practitioners (which is fraud).
What do I do now?
Review the denial notification (These are not easy to understand for anyone – even some doctors can’t read an Explanation of Benefits. Ask for help from your provider, insurance company, a friend, me, anyone, if it’s confusing)
Contact your provider
Contact your insurance company.
Ask them why
Ask what can be done to correct the claim
Sometimes it is a simple processing error. (Once my annual woman’s exam was processed by my health insurance as if my husband was the patient, despite this clearly being inaccurate. It was reprocessed correctly without an appeal)
Other times the doctor didn’t provide enough information, or the insurance company needs to see case notes.
Gather the documents you need (medical records, test results, practitioner notes)
File the internal appeal: This information is on the explanation of benefits, and sometimes you can do this through your health insurance online portal.
If you need to fax the appeal, then keep a copy of the sent receipt. (I use e-fax.)
If you need to snail mail the appeal, then note the date and time you sent it or even send it certified mail return receipt. (I say this after having my private insurance claiming they did not receive documents multiple times.)
Learn about the appeal process:
DEADLINES are important (set calendar reminders, whatever you need to follow-up on these)
Know what to do next if the appeal is denied: Sometimes you file an external appeal, sometimes you have another level of internal appeal
If you are struggling with the process, then contact your State’s Insurance Department (often there is a regulatory body like an insurance bureau and a group that helps navigate appeals)
Only some people file appeals – know your rights.
Gupta, Collins, Roy, and Masitha (2024) used information from a survey by SSRS that included work-aged insured US adults from April 18 through July 31, 2023 to look at insurance denials and appeals. Of the adults they reviewed, 45% of insured working-aged adults were charged for a medical bill or copay for services they though should be covered by health insurance. They noted the following in a Commonwealth Fund publication
Less than half of the 45% who reported the errors challenged the errors. Why? The most reported reason said they didn’t know they had the right to challenge a medical bill.
About 2 of 5 who challenged (i.e., appealed) their bill, reported it was reduced or eliminated by the insurance company.
17% reported that their insurer denied coverage for care recommended by their doctor; more than half said neither they nor their doctor challenged the denial
About 6 of 10 adults who experienced a coverage denial also experienced delayed care
There are many issues cited in this report including how complexity of US health insurance has affected patients. These patients may struggle to understand what is and what isn’t covered and their financial liabilities.
Personally, even selecting a health plan each year is complicated by terms like the following:
HMO
PPO (but some of these are really HMOs pretending to be PPOs)
POS (point of service)
In-network deductible
Out-of-network deductible
In-network max out of pocket
Out-of-network max out of pocket
Wait! There’s more! Then you have 105% of the maximum allowed medicare rate for out-of-network
Then how much of the out-of-network bills go toward your deductibles? Does all that go toward the max out of pocket out-of-network? (You’d be surprised.)
Does the coverage change based on the service? (Yes.)
Do they change coverage based on the service provider? (i.e., facility vs. clinic)
Are there a maximum visits?
With my insurance cover allied health services (i.e., speech-language pathology, physical therapy, and occupational therapy)? How many visits per year? Are these capped individually or across services? Copay? Are there exclusions?
The list goes on…
What can I do if I lose the appeal at all the levels available?
If your plan is through your (or your spouse’s) employer: Explain the issue to HR at your company. There might be something in what they negotiated that could change the situation, or they could negotiated better benefits for the next plan year. Some employers even have support available for employees in these instances.
Advocate. You could also contact your State and Federal representatives to express your frustration regarding the situation and request a change to requirements for healthcare insurance that would prevent this from happening. This won’t take care of the current claim, but it might lead to change in the future.
Here are two TikToks from my personal experience navigating claims with my private insurer.
Health insurance denials and claim mishandling are something I have experienced for years. These are merely a few. I wanted to get this out for the ABC News report that Dr. Glaucomflecken mentioned but it seems the account is gone.#healthinsurance#healthinsurancedenials#chronicillness#navigatinginsurance @Dr. Erin Nance 🇺🇸 @Dr. Rubin, MD @Dr. Glaucomflecken @ABC World News Tonight @Aaron Parnas @UnderTheDeskNews
Disclaimer. This article is based on research and personal experience. This information is not intended as legal advice or healthcare advice. This is informational and parts not from research or able to be documented in my EOBs/experience with my personal private insurance would be based on my personal opinion.
Disparities across income, education, race, and ethnicity
Hoagland, Yu, and Horny (2024) examined the association between patient demographics and insurance denials for preventive care among a cohort of 1,535,181 privately insured patients seeking preventive care in the US.
What preventive care was considered in this study? Contraceptive administration, breast cancer screening, cholesterol screening, colorectal cancer screening, depression screening, diabetes screening, and wellness visits.
Here is a summary of their findings:
Patients with low incomes (<$30,000 yearly), high school degree or less, and from minoritized racial and ethnic groups experienced higher rates of claim denials. Most frequently these were noncovered service-diagnosis code pairs and billing errors. (What does this mean? People’s access to basic preventive care is different based on their demographic – or income, education, racial, and ethnic background. This is considered inequity)
Income: The lowest income group (<$30,000 yearly) had 43% higher odds of any denial than those in the highest income group (benefit denials and billing errors; statistically significant).
Race and Ethnicity:
Non-Hispanic black patients had 19% higher odds of denials compared with non-Hispanic white patients
Hispanic patients had 16% higher odds of denials compared with non-Hispanic white patients
Asian patients had 54% higher odds of denials compared with non-Hispanic white patients
Education:Differences were not statistically significant
Did practitioners resubmit bills (i.e., file the bill again) after denials?
32.4% of practitioners resubmitted the claims.
What amount was unpaid by health insurance? The mean (average) of the unpaid denied claim was $1395. This was left to patients 92.85% of the time and varied by patient income, race, and ethnicity.
Low-income patients had a higher burden than high-income patients (medians of $412 vs. $365, respectively)
Non-Hispanic black (median $390), Hispanic (median $464), and Asian (median $522) patients each facing higher costs than non-Hispanic White patients (median $357)
Smaller differences between less-educated patients (median $384) compared with those who had more education (median $399)
Financial burden for those with disabilities, chronic illness, and chronic disease
Note. I struggled to find research addressing this topic as a disparity, and I know I am not including everything out there. Please share any additional information in the comments or email me.
Below is a summary of what I found.
Increased chronic health conditions = increased financial burden. The more chronic conditions a person has is associated with an increased financial burden (i.e., increased debt, increased medical debt in collections, and increased out-of-pocket medical costs; Becker, Scott, Moniz, Carlton, & Ayanian, 2022)
Medical debt = worse population health. Medical debt is associated with worse population health (i.e., more days of poor physical and mental health, loss of years of life, higher mortality rates for all; Han, Hu, & Zheng, 2024)
Most (85%) do not file formal appeals (appeal rights vary based on coverage as do the rules; the process can be complicated)
Often those who need to appeal the health insurance decisions use a lot of health services, and may be too sick to advocate for themselves. (There are programs, Consumer Assistance Programs, available to help; however, they don’t exist in all states and Congress hasn’t appropriated funds since 2010.)
Keep in mind that most of this information describes associations between chronic conditions, medical visits, and financial burden. This means that the values of the variables (e.g., chronic health conditions and financial burden) provide information about each other. This doesn’t mean that more chronic health conditions causes more financial burden, BUT it does mean we can predict the financial burden more accurately when we know the number of chronic health conditions a person experiences.
But implementing such policies will take time and working with both State and Federal elected officials.
What can you do in the in the meantime?
Monitor your medical bills
Know your rights
Ask questions
If you don’t understand something your provider puts on a bill OR your insurance company has on the “Explanation of Benefits”, then ask. (You can even ask me)
But please don’t ignore the error. And I understand how exhausting this is. It isn’t easy. It’s frustrating. It is disheartening. It’s overwhelming.
Disclaimer. This post is not medical or legal advice. It is informational in nature with some information regarding the author’s opinion.
In honor of Dyslexia Awareness Month, here is a 1993 article, Dyslexics Overcome Barriers, that I wrote for my high school newspaper.
I interviewed some of the students at school who had dyslexia as well as some of the teachers who were trained in Alphabetic Phonics (an Orton Gillingham based program) and worked with the dyslexic students.
Dyslexics can provide so much insight into their challenges as well as ways to support them, but so often it seems they aren’t asked for their insight. I’ll go over this more in a future blog, but for now, just consider what these students said in 1993.
Disclaimer. This article is from 1993. The knowledge base about dyslexia has expanded much since that time. This post is only to provide historical insight not diagnose or treat.
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