Insurance, Part 2: The Rules of the Game

By Granville Brady, AuD

Hearing aids are not a fully covered benefit in most insurance plans. Some carriers provide limited coverage, but be sure you understand all the rules, restrictions and reimbursement policies before you play the insurance game.

For example, an insurer may say it pays a fixed amount, such as $750, and that coverage is limited to once every three years. If the contract with the insurance company states that the audiologist will accept assignment, you might get $750. If there is no restriction on balance-billing the patient, you can get the difference between your charge and the amount paid by the carrier. Some plans state on the remittance advice that the provider cannot balance-bill the patient. The result is that you get $750 for a hearing aid that cost you a lot more!

If the insurer does not allow you to bill for the balance of the hearing aid, do not sign up with them. You could sign up as an audiologist to do diagnostic testing but forego the hearing aid part. Some union plans have set limits that are not favorable to the audiologist.

An illustrative case: One insurer pays poorly for hearing aids but pays well for testing. Consequently, with this company I am an audiology provider only, not a hearing aid dispenser. If a patient needs amplification, I am not restricted from charging them for the aids. If the patient does not want to buy from me, he can attempt to find a provider that handles hearing aids. Since most hearing aid coverage is limited, no matter where they go, most of my cases will allow me to fit them. I give the patient a good discount and fit them with a quality low-end digital aid. But even if the patient goes elsewhere, I have gotten paid for testing.

In other instances, the insurer pays a set amount but does not restrict the audiologist from having the patient pay more for better instruments. A new scheme in this type of coverage is to have a two-tiered system that favors one provider over another. Even though you are a stellar audiologist with an advanced degree, the carrier steers patients away from you by giving a higher discount to a preferred provider. This might be a chain of hearing aid stores that has negotiated a deal with the insurance company to get more business. For example, the insurer tells the patient that the benefit is "up to $750 but no less than $350." If the patient goes to the preferred provider, they will get the full $750 but if they go to you, the amount is lowered to $350. You can usually compete on price, but the feeling that the patient gets is that you are somehow less qualified. It is a subtle form of discrimination. In such cases, I tell the patient that I will not accept assignment but will give the patient a paid receipt that he can send to the insurer. For some reason, having patients send in their paid receipts, rather than me directly billing the insurer, has resulted in receipt of the full $750. Maybe the clerks who work for the insurer haven't caught on yet!

Some plans designed for middle and upper management pay 100 percent of the cost of hearing aids. However, you need to ask the question: "What does the 100 percent payment cover?" If, for example, you fitted a pair of high-end digitals and billed $5,900, would that be the amount the insurer would pay? Or would they pay an amount based on what they believe to be usual, customary and reasonable? Would they pay a lesser amount because you are "in network?" The $5,900 billed might turn out to yield a 40 percent discount rate based on your participation in their plan. The insurance company rationalizes that being "in network" gives you access to a greater volume of their patients, so they knock 40 percent off your payment. In the insurance game, beware of the 100 percent benefit. It is usually better to bill at the manufacturer's suggested retail price. $

Disclaimer: The information contained is not to be construed as legal advice. Every insurance company is different and each state has its own regulations.

Granville Brady, AuD, practices in East Brunswick and Clifton, NJ. Contact him at drgranbrady@optonline.net

Definitions

Preferred provider–member of a group of physicians and other specialists that contract with the insurance company to provide diagnostic and treatment services.

Usual, customary and reasonable—the amount typically charged for a service. The amount charged to insurance companies by providers might be greatly reduced from what a private patient pays, based on the leverage insurance companies have with providers.

From "Insurance Primer," pg. 26, ADVANCE for Audiologists, January/February 2008