Falling Forward Into Success: Insights on Operating a Balance Center

Interview with Dr. Danielle Dorner, Audiologist, Overland Park, Kansas

AP: Tell us about your career path and what got you interested in balance.

DD: My grandfather was in a tree-trimming accident the summer before I entered high school. He suffered a traumatic brain injury and was hospitalized. He was given a 1% chance of surviving, but, against all odds, he made a full recovery. One of his only residual symptoms was transient vertigo with position changes. He ended up seeing an audiologist who diagnosed and treated him for BPPV. The clinic was gracious and allowed me to shadow for a week, as a high schooler. I saw everything from cochlear implants to comprehensive vestibular evaluations. This solidified my decision to be an audiologist. I guess I was a very persistent/determined (some would argue stubborn) 14-year-old. I feel fortunate that I knew I wanted to be an audiologist at such a young age and had resources available to facilitate my career path.

Fast-forward to graduate school, I was torn between two passions: pediatrics and vestibular. I ultimately settled on vestibular because of the intricate testing and evaluation process. I loved how it can be so black and white, but grey at the same time. The research behind diagnostic testing, treatment options, and clinical indications are always evolving. I had wonderful mentors who encouraged me to pursue private practice, which is how I found Associated Audiologists Inc. in the Kansas City metro area. I was drawn to the practice by their research/best-practice based approach, comprehensive care, and provider retention. I did my externship here, where my passion for vestibular was fostered and matured.

AP: What are some of the biggest challenges associated with starting a balance center?

DD: Cost and reimbursement. Almost each billable test requires a separate piece of equipment, which can be costly. Equipment manufacturers can change hands thus rendering replacement parts obsolete or unfixable. It seems like every year reimbursement rates are cut. You cannot necessarily counter that with cutting appointment times, because a VNG does not take you any less time, even though it is now “valued” as less.

AP: Please share some insights on start-up costs. Besides investing in the equipment, what are some other costs associated with a balance center?

DD: Marketing and start-up can be very costly. Actual start up costs vary depending upon what equipment you already have including what marketing and online presence already exists. Based on different factors, start up costs for vestibular services could range from $50,000–$175,000. Marketing is direct physician outreach in the form of print, in person, or consumer ads. One thing I always say is, your time is often worth more than money (the time spent finding appropriate referrals and counseling them on when/how to refer). I have spent hours traveling to meet different physicians, physical therapist, chiropractors, dentists, retirement communities, etc. It can be extremely tedious and costly. However, once you establish a good working relationship, it is extremely rewarding.

AP: Billing, coding and credentialing seem to be a huge task for many audiologists, what are the unique challenges in that area associated with balance?

DD: Because there are more billable codes compared to traditional audiometric testing, there are more changes and variables to keep track of. For instance, VEMPs (vestibular evoked myogenic potentials) used to be a 92700 (unlisted CPT) code. In 2020, it was FINALLY recognized as not an “experimental” procedure. Medicare will pay for these tests. However, other government, and private, insurance companies still have not updated their systems, like Tricare. Understanding how and what to bill along with what is or isn’t reimbursed becomes critical when programs are reliant on third party payers/reimbursement. Also, with Medicare, you must consider PQRS/MIPS. We must ensure we are positive reporters by asking all the right questions and documenting everything correctly.

AP: Without sharing too many details, how does reimbursement for balance assessments compare to other procedures conducted in your clinic?

DD: That is a tough question to answer. I would say reimbursement is mediocre. Does it cover our time and expertise? Sort of. We generate some private pay revenue from non-covered treatment services which aids the program. In addition, the strong reputation of our vestibular program builds and maintains important physician and community referral networks that benefit the entire practice. When appropriate, I am also able to discuss the important benefits of better hearing and refer patients to our team members who can provide hearing aids. A unique recent challenge has been patients who have high deductible plans and don’t fully understand how their insurance plan works. Since vestibular services are time intensive and complex, the total cost for an appointment is higher than a typical hearing evaluation/ consult. This sometimes leaves a patient with a high deductible health insurance plan with a $350 or higher bill. We do our best to pre-educate patients and provide every patient with an invoice following our procedures, but it still seems to be patientsmisunderstanding of how their specific insurance plan works.

AP: Let’s talk about referral sources and patient flow. From where do most of your balance patients get referred? How much time do you allot for balance assessments? How much time during a typical week is spent conducting balance assessments?

DD: Our referral sources vary from primary care, to neurologists, to existing hearing/vestibular patients. Interestingly, we are getting more and more cardiology referrals, which makes sense. A lot of “ruling out” for dizziness includes the cardiovascular system. Our new patients are scheduled for 2 hours. During this appointment we conduct every test medically necessary to rule out/in a vestibular issue. I make the comment to my patients, “at the end of this appointment I want to say that we have exhausted your ear.” Sometimes we must rely on imaging for definitive diagnoses, but my goal is always to have the patient leave knowing, it is or is not their ear causing the issue. I typically see 3-4 new patients a day. For average sake, we can say I would spend 30 hours a week doing comprehensive new patient evaluations. The rest of my time is doing follow-up care or medical management audiometric testing (e.g., sudden hearing loss).

AP: How do you market your balance center?

DD: We have multiple “touch points” for existing patients, potential new patients, and referral sources. Our marketing plan focuses on print and digital/online approaches which include topic-specific blogs, keyword and SEO through our website, patient newsletters (both print and email), and physician/ provider newsletters with one topic per year related to vestibular. New physician referrals always get a vestibular and practice-wide marketing packet. Patient reports are always mailed to their referring or primary care physician which we also consider part of our physician marketing effort. In addition, we request online or Google reviews following every visit. Over time, because of our large number of positive referrals, it has become its own referral source. In the past, especially at start-up, I did a lot of presentations for local retirement communities and community events.

AP: Besides balance assessments, do you conduct any types of treatment or rehab?

DD: Yes! Unless there is an issue of driving distance, insurance coverage, or body mechanics, I will treat all diagnosed BPPV. In some cases, I have a younger working patient who has a nearly-compensated vestibulopathy and I will recommend a course of at-home vestibular rehabilitation therapy (VRT). Otherwise, for formal VRT, I refer directly to physical therapy. If reimbursement and billing were not an issue, I would love to keep them all in-house. However, as audiologists, we do not always have a good way to bill for our time, especially in more complex cases. Yes, some private insurance companies will pay E&M codes, but the reimbursement rate can still be challenging. I also have a good working relationship with multiple physical therapy groups. We have built a strong referral network over time which benefits are patients.

AP: Do you employ technicians to assist in balance assessments? If so, what is their role?

DD: No. Of course, each state has different licensure requirements for assistants/technicians which poses limitations where I practice. In addition, the cost of equipment, our existing patient load, and space limitations are not advantageous for our practice to employ technicians at this time. However, we do have an audiology assistant who will occasionally assist me in treatment. I also enjoy training the next generation and find it rewarding to work with our fourth year externs.

AP: Any words of advice for audiologist who aspire to opening a balance center?

DD: If you do not want to start your own, find a practice – whether it is private practice, ENT, or hospital setting – that will facilitate your education and knowledge-base for vestibular testing. If you see a need, fill it! There are still plenty of large metropolitan areas that are lacking in vestibular audiologists. It will help set a practice apart. It is so important to love what you do. Like other areas of audiology, vestibular specialty work is extremely rewarding. ■