How to Succeed in the Insurance Game

Author: Kim Cavitt, Au.D.

Here are some tips to help audiologists and their practices survive in the world of third-party administrators and insurance.
  • You need to read the ENTIRE managed care agreement you signed or are about to sign and closely review the fee schedules.
    • You need to ask questions, IN WRITING ONLY, when you have questions or concerns.
      • You may need to renegotiate the agreement.
      • This is not easy, but it is possible if you commit time and resources to this endeavor.
    • The owner or manager, at a minimum, needs a working knowledge of the contract and its allowable rates.
      • Knowing the contracts makes verification of benefits a 1000% easier.
    • You need to make sure that ALL of the items and services you provide are addressed in the fee schedule.
      • You need to know if the payer allows, within the terms of the contract, for a patient to upgrade or have out of pocket expenses other than those related to non-covered services, co-pays, co-insurance and deductibles.
    • You need to be compliant to the terms outlined in your agreements.
      • Enforcement of anti-kickback, false claims, and insurance regulations is on the rise. Audiology is absolutely not immune to this scrutiny.
  • First, you have to realize that YOU put yourself in this situation. As Dr. Phil says, “you can’t fix what you don’t acknowledge”. Other than Medicare, you are a VOLUNTARY participant in these plans. You have to analyze these plans INDIVIDUALLY and determine if the pros of participation outweigh the cons. The data you need to analyze for each payer:
    • How many patients have this payer as a payment source?
      • These are the patients you could potentially lose if you go out-of-network.
    • How much diagnostic and hearing aid net revenue does each payer represent?
      • These are the dollars you could potentially lose if you go out-of-network.
    • How many referral sources send patients who have this payer source?
      • Many contracts indicate that providers cannot refer to out-of-network providers.
    • Because I can now charge my usual and customary rate, at the time of visit, for out-of-network items and services, how many patients would I need to see to make up for the potentially lost insurance dollars?
    • In the case of third-party administrators, can you create a competing product offering (especially if the third-party plan is offering only a discount benefit) instead of signing up for their program?
      • Third-party administrators exist because you sign up to provide care. They need providers to survive and succeed.
    • You need to realize that all business is not good business.
      • Sometimes the best decision you can make for yourself and your patients is to terminate your agreement and become an out-of-network provider.
  • You need to ask the right questions and get the right information at scheduling and intake.
    • Like every other health care provider, you need to take in his or her insurance information at scheduling.
    • You need to verify an individual patient’s coverage, benefits and deductibles prior to any visit that could result in charges over a fixed dollar amount.
    • You need to know if coverage for hearing aids is based upon your allowable rate in your contract (when they say they pay “up to” they typically mean the allowable), a fixed benefit amount, or an allowance and if the benefit is inclusive of all of the items and services related to evaluating and fitting the hearing aid.
    • We need to explore 21st century pricing and delivery models.
    • Third-party payers are never going to provide coverage, upfront, for a defined number of years of service the patient may or may not need.
      • This yields the disparity between our billed charges and our allowable charges.
    • Third-party administrators do not cover this long-term service and patients are accepting of these programs.
    • Patients, consumers and payers have been demanding itemized, transparent pricing and choices for almost a decade. Our failure to explore these options, while continuing to market the product, has created these disruptive pricing and delivery models and third-party administrator growth.
    • We can compete, specifically against these discount programs, if we offer an unbundled alternative.
  • We need to run our audiology practices more like your dentist, optometrist, chiropractor, or podiatrist runs theirs and less like that of a hearing aid dispenser or retailer.
    • We need to value our unique skillset and consistently provide evidence based hearing, tinnitus and balance care.
      • We need to show this to every patient.
    • We need to consistently patients privately for non-covered services and explain their value to the patient.
        Nothing is free!
    • We need to collect patient responsibility (co-pays, deductibles and co-insurance) at the time of the visit.
    • We need to collect payment at time of visit.
    • We need to assist patients with maximizing their insurance coverage and benefits BUT we must also realize that fights for coverage should be between the patient and their payer.
      • It was the patient who chose this plan and its coverage limitations.
  • We need to stop listening to the hype and thinking that every patient needs a top of the line hearing aid.
    • The research and evidence does not support this belief.
    • Many patients are very successful users of analog technology (i.e. Lyric).
    • It is this mindset that has led to the growth of third-party administrated delivery and online solutions.
      • Too many patients were upgrading their products and were unhappy. They complained, in turn, to their employers and insurers.
    • Patients should be offered an instrument that is audiologically appropriate for their hearing loss, lifestyle, listening needs, and dexterity limits that is within their insurance coverage limits.
    • We know that the key to success with amplification is not merely the device itself but the evidence based evaluation, selection, fitting and rehabilitation that audiologists provide.    
Kim Cavitt, Au.D. 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 as President of the Academy of Doctors of Audiology and 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.