Audiologist provider participation in managed care, whether Medicaid, Medicare, Medicare Advantage, commercial health plans, or hearing benefit plans/third-party networks is a constant point of discussion, angst, and opinion. I am asked all of the time: Should I be in-network, or should I be out of network? My answer: That is 100% an individual decision for you and your practice and NO ONE should judge the decision you made. In my work, I get to see the forest beyond your individual trees and look under the hood of many, many audiologists and the participation decision is one that requires analysis, data, and thought about what you want your practice to be and represent in your community.
Over the next week, I am going to discuss the pros and cons of network participation (this will be posted on my LinkedIn and Facebook profiles). To get us started, let’s start with some indisputable facts:
- Audiologists are considered to be health care providers by licensure boards and health plans.
- Audiologists cannot opt out Medicare.? We must be enrolled as a participating or non-participating provider or all of our Medicare covered testing, all of the time, must be no charge, regardless of payer source.
- Medicare has clear coverage policies for diagnostic testing and does not cover anything related to the fitting or modification of a hearing aid.
- Just because the outcome of testing is a hearing aid does not mean that Medicare would not legitimately cover the test; coverage is about medical necessity and whether it was met.
- All health plans cover items and services when medically necessary and medical necessity should be documented in the medical record.
- Health plans determine what is medically necessary for coverage and document that in medical policies and guidance.
- Hearing aids and auditory prosthetic devices are all Food and Drug Administration regulated medical devices. They are not retail products.
- Prescription hearing aids can only be dispensed on the prescription of a provider eligible to prescribe (state law determines this). Again, they are not retail products.
- We cannot go out and advocate for increased access to audiologic care and new CPT and HCPCS codes and market the value of treating untreated hearing loss and then be mad when health plans cover the items and services needed to evaluate and treat audiologic and vestibular conditions we indicated were vital to treat.
- Every health care profession and discipline have insurance issues; we are not unique or special.
- Medicare Advantage is not a bad decision for every Medicare beneficiary.? It, too, is an individual decision based upon the patient and their unique needs and desires.
- Every Medicare Administrative Contractor, state Medicaid plan or Medicaid MCO, Medicare Advantage plan, commercial health plan, and hearing benefit plan/third-party network is not created equal.?
- Audiologists and hearing aid dispensers are, as a whole, underinformed on compliance, coding, and insurance and how to operationalize each in their practices.
Audiologists need to do some soul searching, some market analyses of their community makeup, and some data collection and review and ask themselves:
- Am I healthcare provider or a retail salesperson? It is very hard, in the US, to be both. Neither is better than the other. It’s this contradiction that makes managing managed care so difficult.
- Is my competition in or out of network?
- What would happen to my practice if I dropped ________ (name the insurance)? You have to ask this question for each health plan or hearing benefit plan/third-party network.
- Have I done everything I can to learn how to operationalize managed care in my practice?
My next post will focus on the pros of network participation.
