The Changing Rules of Insurance and Hearing Aids
Author: Kim Cavitt, Au.D.
Reimbursement experts are seeing significant changes in the provision of hearing aids through third-party payers. More and more third-party benefits are being processed by and through provider and third-party networks. More payers and plans are clearly defining their regulations and requirements for payment.
I define “successful reimbursement” as this:
Kim Cavitt, AuD is available to assist ADA members with their managed care issues and help you create solutions for your specific situation. You can reach her at kim.cavitt@audiologyresources.com. This is a no charge, value added benefit of ADA membership. Dr. Kim Cavitt was a clinical audiologist and preceptor at The Ohio State University and Northwestern University for the first ten years of her career. Since 2001, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. She currently serves on the State of Illinois Speech Pathology and Audiology Licensure Board. She also serves on committees through AAA and ASHA and is an Adjunct Lecturer at Northwestern University.
Reimbursement experts are seeing significant changes in the provision of hearing aids through third-party payers. More and more third-party benefits are being processed by and through provider and third-party networks. More payers and plans are clearly defining their regulations and requirements for payment.
I define “successful reimbursement” as this:
- The provider understands the terms of their provider agreement and is knowledgeable of the payer guidelines, policies, or regulations.
- The provider verifies eligibility, deductibles, co-insurance and coverage.
- The provider collects, on the date of service, the costs associated with non-covered services (after the patient completes all required notices of non-coverage), deductibles and co-insurance.
- The provider bills the payer for the hearing aid and services rendered (if the benefit is not inclusive), using appropriate modifiers when needed, on the date the hearing aids are dispensed.
- The payer processes the payment in accordance to the patient benefit and the payer specific guidelines, policies, or regulations and the terms of provider agreement.
- United Healthcare: Example 1 and Example 2.
- BlueCross Blue Shield Association (specific state examples): Example 1 and Example 2.
- Aetna
- Medicaid: Each state and managed Medicaid payer has its own policy.
- An unbundled practice can often do better (as long term care becomes the responsibility of the patient) in managed care situations.
- Requirement for a signed medical clearance from a physician, possibly even an otolaryngologist
- May also need evidence that the patient was actually physically seen by the physician.
- Requirement for a manufacturer’s invoice.
- This ensures, to the payer, that the patient was fit and was fit with actual Class I or II hearing aids.
- It ensures that the payer is providing coverage for hearing aids which were actually paid for by the provider, and not free.
- Please note that, in the past, I have advised against supplying manufacturer’s invoices. My opinion has changed. Payers need to ensure that the items and services were provided prior to payment.
- Please be careful of submitting inflated manufacturer suggested retail price (MSRP) or “faux” invoices. Remember that these third-party payers all now have strong relationships with provider and third-party networks and are aware of the wholesale cost of hearing aids. Never submit MSRP unless specifically allowed to do so, in writing, in your provider agreement or payer guidance.
Kim Cavitt, AuD is available to assist ADA members with their managed care issues and help you create solutions for your specific situation. You can reach her at kim.cavitt@audiologyresources.com. This is a no charge, value added benefit of ADA membership. Dr. Kim Cavitt was a clinical audiologist and preceptor at The Ohio State University and Northwestern University for the first ten years of her career. Since 2001, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. She currently serves on the State of Illinois Speech Pathology and Audiology Licensure Board. She also serves on committees through AAA and ASHA and is an Adjunct Lecturer at Northwestern University.