Cochlear Implants Go Mainstream with the Cochlear Provider Network

Author: Janis Gasch, Au.D., Greg Swingle, Au.D., Kristi Hesse, Au.D.

Cochlear implants (CI) are the standard treatment for bilateral, severe-to-profound hearing loss. It is estimated there are over 30,000 recipients implanted per year worldwide (Vaerenberg, et al 2014). Yet cochlear implant audiologists remain subspecialists within the audiology profession. In many medical centers in the United States, cochlear implant audiologists work primarily with children and adults with severe-to-profound hearing loss, participating in the identification, selection, and rehabilitation process of cochlear implantation. Survey data indicate that CI specialization is confined to a small number of audiologists, with only approximately 11% of audiologists who self-identify as working with cochlear implants. This shortage of CI audiologists is likely to impede access to care, but it also provides a tremendous opportunity for audiologists, beyond fitting hearing aids, to participate in the care of adults with severe-to-profound hearing loss.

The Cochlear Provider Network enables audiologists, who do not work directly with otology surgeons, to become directly involved in providing a full range of reimbursable CI services to adult patients. It was created by Cochlear Americas a few years ago to help mitigate challenges related to the paucity of audiologists who specialize in CI, combined with the relatively poor benefit many individuals with severe-to-profound hearing loss receive from their hearing aids.

Because third party insurance and Medicare reimburse for many of the services related to CI, and because non-audiologists who dispense hearing aids are not typically eligible to receive such third-party reimbursements, becoming part of the Cochlear Provider Network can be a differentiator in a competitive marketplace that is about to see the rise of over-the-counter hearing aids and the continued success of big-box retail.

Today, an adult with unaided hearing thresholds worse than 60 dB at 500 Hz, 70 dB at 1000 Hz, and 90 dB at 2000 Hz, unaided single word recognition performance worse than 45% in the better ear and documentation that hearing aid benefit is suboptimal would be within the candidacy requirements for CI (Gubbels, et al, 2017). Because the audiological candidacy requirements have expanded, it is believed a larger pool of patients, many of whom might be experiencing poor hearing aid benefit, are now CI eligible. Thus, a larger number of audiologists, not directly affiliated with a cochlear implant center, are needed to identify and manage these potential CI recipients.

Janis Gasch, Au.D., Founding Director of Arizona Hearing Specialists in Tucson, AZ and two audiologists on her staff, Greg Swingle, Au.D. and Kristi Hesse, Au.D. agreed to an on-line interview about their involvement in the Cochlear Provider Network.

AP: Please describe your practice for A: readers.

JG: We are an audiologist-owned private practice. We provide a broad range of hearing healthcare services, including hearing aid fittings, tinnitus evaluations, aural rehabilitation, and a cochlear implant program. There are 5 audiologists employed (over three offices), and 2 audiology assistants. We have been in practice for 36 years.

AP: How did you get involved in the Cochlear Provider Network (CPN)?

KH: We were approached by an oto-neurologist in town who was working in conjunction with Cochlear Americas. We were attracted to the program because it would provide us the ability to go beyond hearing aids, and provide continuity of care for those that were being referred for CI. Additionally, it provided an opportunity for our providers to use more of their knowledge, and therefore increased their satisfaction in their chosen career. The CPN has also allowed us to diversify the services provided by our practice, and build stronger relationships amongst our local audiological and ENT community.

AP: How long did it take to become proficient at CIs, and how did Cochlear help in this endeavor?

GS: It took approximately 1-2 years to gain proficiency, keeping in mind this is only a small aspect of our total patient population.

Cochlear was a huge help in this endeavor. They provided in-office support, as well as full day trainings. We developed a schedule with our Cochlear rep where she was scheduled to be in our office 2 times each month and we would schedule all of our patients on those days so that we had the necessary support.

Additionally, they have a support structure in place to help reduce the workload associated with non-billable services necessary for our CI patients.

AP: Describe your CI evaluation process. What tests do you use? Also, please describe the role of the audiology technicians in this process.

GS: In order to determine CI candidacy, we perform a comprehensive audiological evaluation including tympanometry, reflexes, pure tone air (125-8K including 3k and 6k), bone conduction, SRT, word recognition and QuickSIN. Additionally, we test Az Bio Sentences in each ear individually as well as binaurally in the following conditions: quiet, SNR of +5 at 0 degrees azimuth. We also test CNC in each ear individually as well as binaurally. Audiology techs are used to check in the equipment and do many of the administrative tasks, but the audiologist performs all testing, mapping, and aural rehabilitation.

AP: Walk us through the process for those CI candidates you identify.

KH: Upon arriving for their appointments, patients are given a questionnaire regarding their expectations for the CI process, and they complete it prior to coming back for the evaluation. If the patient is new to our office, they are initially seen for a 2-hour CI candidacy evaluation. During this appointment, tymps, reflexes, a comprehensive audio, SRT, word rec and QuickSIN are performed; if the patient appears to be a candidate for CI, hearing aid performance is verified using real ear measures. If the patient is not appropriately fit, they are fit with a pair of premium hearing aids that we keep in office for this purpose. Once we have verified that they are using appropriately fit hearing aids, we perform AZ Bio Sentences and CNC testing in sound field (with those hearing aids). If the patient is an existing patient of our office, they are often scheduled for 90 minutes since we have typically already verified their hearing aids.

Once it is determined that the patient is a CI candidate from an audiological standpoint, they are counseled on CI expectations using the questionnaire that was already completed. They are given reading materials on CI and are given a sheet of paper with instruction on how to contact the surgeon’s office. We explain that the surgeon will evaluate whether or not they are medically a candidate. All reports and testing are sent to the neuro-otologist. Once he sees the patient he sends back a report with a plan. If the patient chooses to proceed, they return to our office for a final discussion regarding equipment and any other questions prior to their surgery date. They are then scheduled for their activation date (approximately 2 weeks post-surgery).

AP: Once a CI patient has gone through the initial activation and mapping process, how often do you typically see them back for care and service?

GS: The patient is seen for initial activation 2 weeks post-surgery. They are then seen 2 weeks after that for follow-up mapping. They are then seen 2 weeks after that for their one-month testing/mapping appointment. The patient is scheduled for one a one-hour appointment where testing is completed (unaided thresholds, aided thresholds, Az Bio testing and CNC testing). A week later they are seen for another one-hour appointment for mapping. This process is then repeated at 3 months post-surgery, 6 months, 12 months, 18 months and 24 months post-surgery. Additionally, the COSI and Glasgow are administered during the first year.

AP: Many providers believe that CI services are time consuming and not lucrative. How would you argue against those beliefs?

KH: While CI testing/mapping may not be profit-generating, it is extremely beneficial in other ways. It is a service to the community, it provides increased job satisfaction to the providers, and provides positive branding and diversification for the audiology practice. Being part of the CPN allows our clinic to see a broader range of patients, which also means that we have a larger referral base (because those patients have friends and family who may benefit from our services).

AP: Let’s discuss revenue generation in a little more detail. How can practices generate revenue by being part of the CPN?

KH: There must be a solid understanding of billing procedures and codes, and you must have the structure and confidence in place to bill for the services that you provide if they are not covered by insurance. This is critical, and we have resources within the CPN to help with this aspect of things.

A practice is also able to market to a broader patient population. More patients coming into our practice means more potential friends and family referrals. Physicians are also more likely to refer to our practice because we are more than just “hearing aid dealers”. Patients who use a CI typically wear a hearing aid on the contralateral ear, and they often purchase new technology through our office. So there are definitely ways in which being part of the CPN can help generate revenue.

AP: Are there any opportunity costs? For example, time spent on CI is time not spent on other more lucrative revenue generating opportunities. How do you square this in your practice?

GS: It is definitely important to keep an eye on how the providers spend their time. Hours spent doing CI work are not as lucrative as other types of work we do, so we limit the number of CI appointments we have during the month. However, because CI patients do generate revenue for the practice in terms of referrals, branding, reputation, etc., we see that “opportunity cost” as more of a long-term investment.

AP: What has the CPN done to the brand or reputation of your practice within your community?

GS: We are more highly esteemed in the community, because we do more than just hearing aids. We are seen in a more medical model, and we are viewed by physicians as a more reputable hearing healthcare provider because they have the confidence that we can find the best solution for their patients and we are not intent on “just selling a hearing aid.” We care about the whole person, and we try to make sure we address any and all aspects of their hearing healthcare needs.    
Janis Gasch, Au.D. is the founding director of Arizona Hearing Specialists, Tucson, AZ. Greg Swingle, Au.D. and Kristi Hesse, Au.D. are clinical audiologists at Arizona Hearing Specialists.
Gubbels, S. P., Gartrell, B. C., Ploch, J. L. and Hanson, K. D. (2017), Can routine office-based audiometry predict cochlear implant evaluation results?. The Laryngoscope, 127: 216–222.

Post-Surgery Follow-Up Schedule
    2 weeks post-surgery
    4 weeks post-surgery
    (unaided thresholds, aided thresholds, Az Bio testing,CNC testing*)
    6 weeks post-surgery
    7 weeks post-surgery
    3 months post-surgery
    6 months post-surgery
    12 months post-surgery
    18 months post-surgery
    24 months post-surgery
* Administer COSI and Glasgow during the first year.