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:
  • 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.
Providers have a significant role in successful reimbursement. First, read your provider agreements and review your fee schedules. Also, you need to be aware of the policies, guidelines, and requirements available from the payers. Many of these guidelines are available on their websites and are released in their monthly provider bulletins. THIS is how they inform you of the policies your practice is now obligated to if you are a participating provider. Here are some examples:
  • 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.
Some things you need to be aware of as now common in new guidance:
  • 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.
A final note, you and your practice are voluntary participants in the large majority of managed care. Except for Medicare, you have the ability to be out of network and to charge most patients privately for the items and services provided. When you agreed to participate in managed care, you agreed to accept discounted rates. There are solutions and alternatives to many managed care situations. It just takes being open to change, patience, and a bit of elbow grease.

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.