10 Things Audiologists Need to Stop Doing If In-Network with Insurance

Author: Kim Cavitt, Au.D.

The business practices outlined below effect the perception of our profession by health plans and patients. They also help drive health plans to third-party networks and administrators. These are choices being made by providers and their practices. There are many audiology practices that do not do any of these things yet are still profitable and financially and clinically successful. If state or federal governments or health plans were to choose to audit audiology and hearing aid claims, many providers and practices would not survive these audits without claims repayment or further legal scrutiny.
1. Do not provide free hearing tests (any aspect of 92557) to some patients and then bill a health plan for the same hearing tests.
If the service is free to one individual, it should be free to all individuals. This has been clearly documented. The ONLY exceptions are indigence or if your practice were to ONLY bill insured patients.

The solution: Bill the patient or their health plan for all services rendered and items dispensed and stop providing free care.
Do not bill a health plan for hearing aids that have yet to be fit.
This is an example of a false claim (another example). There are no loop holes around this (i.e. fitting a patient with a loaner or demo set of hearing aids).

The solution: Verify coverage and benefits, fit within the hearing aid benefit, applicable medical policies, and coverage allowances and bill hearing aids on the date of dispensing.
Do not fit stock hearing aids on a patient and bill the hearing aids to a health plan.
Medical necessity for the item being dispensed must be documented in the medical record. Many payers, in their coverage and benefits language, medical policies, or contract language require a manufacturer’s invoice be submitted when requested. Also, some health plan’s allowable is based upon a percentage of the manufacturer’s invoice cost and, as a result, the invoice must be submitted as part of the claims process. This invoice must reflect the actual invoice cost (and not single unit or MSRP), be dated after the date of the hearing aid evaluation and should contain the name of the patient.

The solution: Select and order hearing aids for each specific patient from the manufacturer following the communication needs assessment/hearing aid evaluation when a health plan is paying in whole or in part of the item.
Do not bill a health plan for an item you received at no charge.
This is a potential violation of false claims and anti-kickback legislation and has been well documented in healthcare (another example ).

The solution: If the item was free, provide it to the patient for free.
Do not bill services provided by unlicensed or non-credentialed provider to a health plan under another provider’s national provider identifier.
Recent graduates are unlicensed providers. They cannot see any patient, regardless of payer, until they are licensed (unless their state has clear provisional or temporary licensure or privileges, which is not common). The newly licensed and new employees cannot see patients and bill the items and services to a health plan until the audiologists are credentialed providers for the health plan (with few exceptions). Otherwise, this is a false claim (another example).

The solution: Do not begin employment as an audiologist until licensure is conferred and do not allow audiologists to see patients where insurance claims are being submitted for covered services until the provider has been credentialed with the health plan.
Do not market to existing patients that they are “due” or “eligible” for new hearing aids.
This can be seen as a solicitation or as potential fraud, abuse or waste when medical necessity for the replacement device has not been clearly documented (another example). Some health plans, including most state Medicaid programs, have medical policies that clearly require documentation of medical necessity (not just that the eligibility date has arrived) for replacement devices.

The solution: Recommend, fit and bill health plans for replacement hearing aids when it is medically reasonable and necessary to replace existing hearing aids.
Do not assume an item or service is non-covered just because the treatment plan includes hearing aids and, as a result, charge the beneficiary privately for the service.
While Medicare does not cover “examination for the purpose of prescribing, fitting, or changing hearing aids” or “routine” services, coverage of audiometric testing is not automatically precluded JUST because the patient is a hearing aid user or because the treatment plan includes hearing aids. The Update to Audiology Policy indicated: “It is appropriate to pay for audiological services for patients who have sensorineural hearing loss and who wear hearing aids if the reason for the test is anything other than evaluation of the hearing aid. For example, there may be a perceived change in hearing or tinnitus that makes testing appropriate and covered. Such testing might rule out other reasons for the symptoms (auditory nerve lesions, middle ear infections) and result in subsequent evaluation of the hearing aid (not covered) or aural rehabilitation by a speech-language pathologist (covered)”. So, in other words, if the testing is physician ordered and medical necessity has been documented, Medicare will cover the testing. The patient should not be held financially responsible.

The solution: Allow the patient to access their health plan benefits by reviewing the patient’s case history, documenting medical necessity for the services provided, and billing the health plan for medical necessary services.
Do not fit hearing aids on normal hearing individuals and bill the health plan, unless explicitly allowed by medical policy.
Many health plans, including state Medicaid programs, Aetna and Tricare, have degree of hearing loss requirements for hearing aid coverage and/or have medical policies restricting coverage of hearing aid for treatment of tinnitus or auditory processing disorders or for hearing protection purposes (for example here, here, and here.).

The solution: When the audiologist is in-network provider, the provider should educate themselves on the contracts terms and applicable medical policies governing coverage.
Do not uniformly upgrade hearing aid technology from a basic or standard item to a deluxe item without documentation of medical necessity for the deluxe item, without first offering a patient a standard item within their benefit, without having the patient acknowledge, in writing, their rights and responsibilities prior to dispensing, and, most importantly, without ensuring that the health plan contractually allows for upgrade.
Every health plan does not allow for upgrade from a standard item to a deluxe item. As a result, the audiologist could be violating their payer agreement by having the beneficiary pay, privately, for anything other than unmet deductible, applicable co-insurance or co-payments, or for prior notified non-covered services. This capacity for upgrade is determined by the health plan and your agreement with that health plan. If the health plan does not allow for an upgrade, the patient is not allowed to upgrade.

The solution: The practice needs to educate themselves on each payer agreement and medical or payment policies, create verification processes and policies and implement upgrade forms and processes.
Do not bill health plans differently than you bill your private pay patients for the same items or services.
Billing in excess of your usual and customary rate to a health plan can be construed as abuse.

The solution: Bill insurance the same rate as you bill your general population for the same item or service.

This list, unfortunately, is not inclusive. There are many, many other areas of concern. All of these listed activities and behaviors are 100% avoidable. This just requires investment (time and treasure) in managed care credentialing and contracting processes, creation of no exceptions office policies and procedures, and obtain education and training on revenue cycle and your office management system capacities. If we want to be doctors and play in the healthcare sandbox, we must begin to provide and bill for care consistent with healthcare rules, regulations and billing and medical policies.    
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.