In a climate of decreasing reimbursements and less-than-cooperative relations between third-party payers and audiologists as a whole, private-pay fees for services will promote solvency and independence.

Medicare and most third-party payers only pay for services that are considered "medically reasonable and necessary," a policy that is subjective at best, but the law is the law.

Although direct access would nationally validate audiology as a doctoring profession and serve the patient by helping avoid unnecessary steps to receive the best available care, direct access will not increase our reimbursement rate and will only increase patient flow over a long period of time as consumers come to understand that audiologists are the hearing doctors. Also, realize that direct access will not eliminate the need for a reason to suspect a "medical problem" in order to qualify for benefits (see Medicare Benefits Policy Manual, Chapter 15, 80.3).

The Medicare benefits policy reads: "The payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis of the patient's condition." If the reason for the test is due to suspect medical issues, a physician order or having a limited practitioner's license through direct access could constitute legal coverage.

As hearing and balance testing are within audiology's scope of practice, the only purpose of a physician order, then, is to ensure coverage. Only utilize a physician order when it is in line with the strict Medicare guidelines. For the good of the profession, physician orders would be limited so we are not as subject to the declining Medicare reimbursement rates. Furthermore, for non-suspected medical issues, it is imperative that we are diligent in directly billing patients for services that are statutorily excluded. For example, if your office has a recall system, those tests should be out-of-pocket expenses paid by the patient, as they are statutorily excluded from Medicare coverage.

While some think it would help if Medicare and other insurance carriers expand coverage of audiology services to include expanded diagnostic and rehabilitative services, as an audiologist in the private sector, I believe this could be the demise of our profession.

If laws were passed to expand coverage for audiological services through Medicare, it is likely that other insurance carriers would follow and we could be tied to an anchor that causes us to drown. It's important to remember that audiology as a profession does not have the option to "opt out" of being a Medicare provider, which is different from being a participating versus a non-participating provider. What this means is that we must provide services to Medicare patients, and we are legally bound to bill Medicare for all of the services we provide that are covered. Expanded services under Medicare would not mean an increase in overall coverage-Medicare is a revenue-neutral program, so whatever is covered in one area would likely be reduced in another. Imagine being bound to a fee schedule that barely allows you to pay your staff for services. Could you continue to offer those services and keep your doors open?

If expanded coverage ever gets close to our horizon, it is imperative that we advocate for the freedom to opt out as can many other providers, including physicians. Otherwise, if reimbursement under Medicare is expanded for diagnostic and rehabilitative services, I believe that:

• Providers may have to offer fewer services leading to less patient access to quality care;

• Reimbursement rates will continue to decrease with a difficult road for recourse or reversal;

• Recruitment of high-quality students for the future of our profession will decrease as the cost of education increases and the prospects for higher salaries decrease; and

• Some of us may be forced to discontinue offering medical diagnostic services and instead provide free hearing testing for the sole purpose of procuring a hearing aid.

If audiologists follow the current "rules," most of our services should already be directly billed to and paid by patients. Embrace this concept: We are not an insurance-driven profession and never have been. Why start now? Charge for your services as indicated by what is not covered by Medicare and third-party payers. Patients will appreciate the quality of care and the value of your services. and the profession of audiology will thrive.

Nancy Gilliom, PhD, has been in private practice in Jacksonville, FL for 15 years. She has been a member of the Academy of Doctors of Audiology for more than 15 years and currently is the editor of its official publication, Audiology Practices.

This article was made possible by a partnership between ADVANCE and the Academy of Doctors of Audiology. For more information on ADA activities, educational offerings and/or membership, visit the ADA website at www.audiologist.org or call ADA at 866-493-5544.