The Importance of Using Notices of Non-Coverage in an Audiology Practice

Kim Cavitt, Au.D.

Notices of Non-Coverage are forms that are almost always required by managed care entities, through their agreements, medical policies, and guidance (when you are in-network) and frequently required by many state governments (when you are an out of network provider). In this notice, you are informing the patient of the recommended items and services to be rendered, why your practice anticipates that these items and services will be non-covered, and the usual and customary costs for the items and services. The patient will acknowledge, through their signature, the receipt of the notice and acceptance of its associated financial responsibilities.

In-network providers typically have contractual responsibilities to inform patients, in writing, of non-coverage of items and services and to document the patient’s acceptance of the financial responsibility for the costs of these items and services. Commercial plans (Indemnity, self-insured, PPO, POS, HMO) typically allow you to use a practice created and generated form. The Academy of Doctors of Audiology (ADA) offers a form, for purchase, through their Forms Library (https://www.audiologist.org/practice/forms-library) that was created by myself and ADA’s legal counsel. This form should be used for ANY items and service, including but not limited to hearing aids, tinnitus management, auditory processing evaluation and management, evaluation and management services, cerumen management, auditory prosthetic device fitting, orientation, and troublehooting, auditory rehabilitation, etc. The form should be provided to the patient prior to services being rendered and should clearly indicate the patient’s financial and professional rights and responsibilities.

Advance Beneficiary Notices (ABNs) are the traditional Medicare (red, white and blue Medicare Card) notices of non-coverage. They have required (where you cannot collect payment from the patient without the form being in place before the service is rendered; when using 92700 , L9900 or when a local coverage determination is in effect in your locality) and voluntary (items and services that are statutorily excluded from Medicare coverage or that do not meet the definition of a Medicare benefit). You can learn more about ABNs at https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN and you can get a pre-filled ABN for required or voluntary uses, at no charge, through the ADA Forms Library.

Medicare Advantage (Part C) plans have their own, unique notice of non-coverage requirements (organization predetermination). This can vary plan to plan and state to state. These requirements can often be found on their websites or in their portals. Some of these plans offer their own, specific notices of non-coverage that are to be used with their members. Others will allow for the use of the practice created and generated form.

Finally, out of network providers need to realize that they are not immune to patient notification responsibilities, especially when dealing with Medicaid beneficiaries. The Federal government, though the No Surprises Act (https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills#:~:text=The%20No%20Surprises%20Act%20protects,network%20air%20ambulance%20service%20providers.) and state governments, through similar legislation and state balance billing protections (https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections) have set forth patient notification requirements that can impact out of network providers. Practices need to seek legal guidance, get assistance on their rights and responsibilities within these laws and determine what needs to be provided to out of network patients and in what settings.

Notifications of non-coverage can go a long way in providing patient’s with pre-determination and price transparency. It also can help alleviate confusion when the patient is interpreting their third-party coverage and benefits and, after claims processing, understanding their explanation of benefits. These completed notices also offer provider’s legal protections in the event of consumer and patient complaints on billing and insurance. ■

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.