Editor’s Note: Over the past few years, there has been a proliferation of third-party programs available to practitioners. These programs appear to provide practitioners with an opportunity to increase their patient load and, ultimately, their revenue stream. In this month’s blog, Dr. Kim Cavitt provides us with an overview of plans offered by third-party administrators (TPAs) and hearing aid referral networks (HARNs), and offers a practical guide on what practitioners should consider before enrolling in such a plan. Having a clear understanding of third-party involvement is paramount to a practitioner’s professional autonomy and the practice’s bottom line.
by Kim Cavitt, AuD
The concept of over the counter hearing aids is extremely controversial within the audiology community. Many believe that these devices and their accompanying delivery model will have a detrimental effect on the profession and its financial viability. Detractors believe that hearing aid consumers will seek self-evaluation, self-fitting, and self-management, and will not seek the evaluation, management, or treatment of licensed audiologists and hearing instrument dispensers.
The hearing aid market is not only being flooded with over-the-counter (OTC) and direct-to-consumer (D2C) hearing aids, personal sound amplification products (PSAPs) and hearables, it is also being flooded by third-party administrators (TPAs) and hearing aid referral networks (HARNs) who market and offer provider-driven care that is directed and managed by a third-party middleman. There are, at least, 14 of these programs currently operating in the United States.
What is a TPA?
TPAs are middle-men between the provider and the insurer, employer, or membership group. TPAs negotiate discounts, coverage, and benefits for the group and administer the discount or benefit offerings. TPAs refer their “members” to registered, in-network providers for evaluation, fitting, and long-term service.
What is a HARN?
HARNs are typically online entities who market, via the internet and social media, significantly reduced, inclusive discount pricing to consumers, have the consumers purchase such devices directly from them, and then also refer those consumers to registered, in-network providers for fitting and service.
Commonality between TPA and HARN
What the TPAs and HARNs have in common is this: they insinuate themselves within the delivery model, sometimes undercutting a provider’s previously existing arrangements, then dictate both care and reimbursement. They do this and then ask providers to join and provide the care to the consumer that they cannot. Sadly, audiologists and hearing instruments specialists are joining these programs in droves, without first carefully analyzing the costs versus the benefits of participation.
Basis for TPAs and HARNs
Now, as someone who used to work for one of these entities, the sheer existence of these programs is, in part, our fault because providers:
- Vehemently refused to itemize or offer any form of price transparency; we failed to offer value based or affordable solutions to consumers;
- Believed every hearing loss could only be treated by a $6000 solution;
- Provided free evaluations and failed to routinely provide evidence-based care; and.
- Finally, and this fact is important, many providers ignored our managed care agreements and played a dangerous insurance game
- where every hearing aid patient was forced to pay for an upgrade;
- where providers billed for hearing aids they had not fit and would not fit until payment was received,
iii. where patients paid-in-full upfront, even though they had a benefit, and,
- where providers charged the payer differently than they charged the general population.
Insurers, employers, worker’s compensation plans, and, most importantly, consumers became tired of the game and got tired of losing, and, ultimately, pushed for a lower cost and defined delivery system. Now, the main losers in the current game are the providers themselves.
All is Not Lost
Not all these entities are evil and that providers should not enroll. Some TPAs and HARNs can and do offer a win-win-win proposition, especially compared to the system and reimbursement many providers faced when dealing with the insurer directly through their own managed care agreement. Some also offer audiologists access to a managed care network in which might not otherwise be able to participate.
Considerations for joining TPAs and HARNs
The TPA and HARN programs are not expected to change and will continue to exist, thrive, and multiply so long as they have providers and consumers willing to accept their products, terms, and payments. When providers participate in programs that are not good for them and their patients, then they become, yet again, their own worst enemy.
When making a participation decision, analyze data from the practice and look at historical, direct from insurance claims, and ask the following questions:
- Can the practice afford to provide the level of care, at the agreed upon rates, required by the plan?
- Is the plan offering a funded or unfunded (discount) benefit? (Psst…you might be able to directly compete against a discount only plan offering.)
- How many current patients are now being represented by this TPA?
- How many dollars do those patients represent?
- Can you afford to potentially lose the patients and their dollars?
- How does the reimbursement from the TPA compare to what the practice used to receive from the insurer and the patient?
- Is it better, worse or similar? Heck, sometimes it is way better.
- Do any of the TPA program terms conflict with the terms of other managed care arrangements?
- Does the TPA give the provider access to a payer and their patients that the practice was unable to contract with on your own?
Analyze the data and information and make a business decision. In the end, the provider must make an informed decision and not a reactionary one based upon fear or lack of knowledge.
The Final Word
Many providers simply react and enroll when a program becomes available in the market, signing up randomly, without every fully evaluating the programs and its costs versus benefits, to both the provider and the patient. Doing so undermines the providers professional credibility and compromises patient care. My aim is that this blog will serve as a wakeup call to providers to truly evaluate each program before they agree to participate or, if they are already enrolled, evaluate the merits of such participation or lack thereof. Rest assured that there are programs out there now where the only winner is the middleman.
About the Author
Kim Cavitt, AuD, 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. Audiology Resources, Inc. provides comprehensive operational, compliance and reimbursement consulting services to hearing healthcare providers. She is a Past President of the Academy of Doctors of Audiology (ADA). She currently serves as the Interim Chair of the Audiology Quality Consortium (AQC), Vice-President of Government Affairs for the Illinois Academy of Audiology and is the Chair of the State of Illinois Speech Pathology and Audiology Licensure Board. She also serves on committees through ADA, AAA and ASHA and is an Adjunct Lecturer and Clinical Placement Coordinator at Northwestern University.
**featured image courtesy lifehack.org