Meagan Lewis, AuD

by Meagan Lewis, AuD


Why? That’s the first question that many have asked when I told them that we were planning to itemize our services May 1 of this year. 

In fact, that’s the first question our staff asked when we started discussing the idea two years ago. 


Hearing Aid Price ‘Bundling’ Isn’t New


We certainly aren’t the first clinic to consider itemizing or unbundling services. I personally know of several other clinics that have been itemizing for as long as 10 years. In fact, the American Academy of Audiology has published a position statement, an itemization guide, online courses, and articles in Audiology Today from 2009.  


But Why Us and Why Now?


The answer to the Why question is multi-faceted, covering the gamut from transparency to value to affordability to education.  

  • Transparency for  patients and value placed on what we do. We, like many dispensing audiologists, see transfer patients. Whether they are people who have relocated or are seeking a second opinion, they often need their current hearing aids adjusted rather than needing to purchase new instruments.

    Previously, we charged a “transfer of care” fee.  I found it difficult at times to explain what the charge covered.  For example,

    Well Mr. So And So, I am charging to take over your care” rather than, “ I am charging you X dollars to adjust your hearing aid to a prescriptive formula that helps ensure that speech sounds are audible.  I can measure that in your ear and ensure that we are maximizing the device.” 

    Itemizing the service helps to explain what we are doing and for what purpose, rather than lumping everything together.

  • Educating the patient who hopefully educates others. Unbundling reminds me of one gentleman who initially came in for a cochlear implant evaluation. He was frustrated (well, his companion was more frustrated and insisted that he take action). He had worn hearing aids for 6 years but struggled to communicate, even in a quiet situation. 

    As part of the evaluation, we evaluated his current, unsatisfactory hearing aids. Unfortunately, the devices were well below target and most speech was inaudible.  I explained that I could adjust the hearing aids and that the charge for doing so was X dollars.  He agreed. When we were done, he said he had not heard that well in 6 years. 

    A former high school principal, he told his former student, now a primary care physician, that all his patients needed to be sent to our clinic because we “are using science to fit them and not our gut.”  As a doctoral level profession, we should be using science. We have science degrees. There are accepted tools and protocols available to increase the accuracy of programming hearing aids, and evidence that these tools improve audibility and satisfaction.  

    Itemization enables us to appropriately charge for services and opens the door for explanation about what that service is.

  • Affordability is also a concern for most of our patients when purchasing devices.  How many times has someone said to you “I’m on a fixed budget and cost is a concern.”?  Many or most. 

    In a bundled model, the services that we provide drive up the cost of the devices. When folks ask, “why is it so expensive?”, one piece of the answer is that our professional time is included in the device.  I want to be seen as the professional and not the product. 

    In an itemized model, I can quote the price of the device, then explain what goes into a hearing aid fitting to make the device effective. We assume when we quote a bundled cost that a person is going to come in an average number of times over the next several years. However, that’s painting with a pretty broad brush. Most long-term wearers are going to require fewer adjustments than new users. It is unfair to charge them the same price for services that they may or may not use, and doing so drives up the overall cost, making hearing aids cost prohibitive for some.

    Offering the option to pay as one receives services spreads the overall cost to the patient and family out over a number of years, so that they pay for what they need.


In the next post, I’ll explore external forces that influenced our decision to unbundle.


Meagan Lewis, AuD is the manager of the audiology department at Wake Forest Baptist Medical Center, a large university and medical school based health care system in North Carolina. Wake Forest, under Meagan’s lead, is an early adopter in breaking away from a ‘bundled “price for hearing instruments. There is much interest in this topic, and Meagan has agreed to share her experiences to date, with periodic updates as the new approach settles in.

feature image from contract express

For any audiologist thinking about itemizing their statements—known in many circles as “unbundling”—some stories from the past might provide encouragement. 

Today, itemization may seem unusual to patients and dangerous to profits, but in past years these actions were common, expected by patients, desirable and profitable.   It further demonstrated that we, as independent clinical providers, were legitimate. 

For the most part, these reimbursement battles were abandoned shortly after the late 1970s when most clinical practices found that it was easier to model billing for hearing aid sales after a traditional sales model, which had been in place since the beginning of retail hearing aid sales.  Itemization for audiologic procedures then disappeared in many clinical offices.




When impedance testing was first introduced into the U.S. in the middle to late 1960s, many argued that there was little clinical information to be learned from measuring acoustic impedance at the tympanic membrane.  After all, determining stapes fixation, which encouraged surgery to repair, was pretty easy to infer when there was a conductive hearing loss in the absence of a perforation or middle ear fluid.

A couple of years later, after a number of peer-reviewed publications, those initial but rushed opinions resulted in a battle to get third-party acceptance.  Having purchased equipment, with hopes of offering more information to both the patient and the referral source, the struggle for reimbursement was a slow process.  No matter how much justification was sent with the “unlisted otolaryngology procedure” billing code, many third parties continued to disallow payment. 

The value of the procedure, to the insurance payer, was only in dollars.  The value to the patient, the physician, and the potential treatment was documentable, precise information.  The research and clinical data was sufficient to eventually gain procedure codes and payment dollars.  But, it was not easy, nor was it quick.  The best battle plan involved arguing the data-driven value of the tests.

Similar trials and tests of persistence occurred with all of the averaged electrical potential procedures.  And, buying or building an averaging apparatus required a lot more up-front investment than an acoustic impedance device.  Knowledge, skill, and persistence paid off in the long run. 

Similar reimbursement resistance has plagued most new procedures in many fields.  Proof of value to third parties is usually a long time coming.




For clinicians just getting started in private practice, there may be temptation when the bank account stays positive for a few months to begin shopping for a car.  Not just any car, but something “cool”.  Has anyone ever calculated how much revenue can be generated in a clinical practice by adding an automobile?  You don’t have to be an accountant to foot that column.  By contrast, how much better off is the clinician who invests in tools of the trade—tools like averaging computers, a modern sound field, probe microphones, or an emissions device—and proceeds with investigations and  data which prove of value to patients of the practice?

What does this have to do with Audiology today?  Well, if you have been following the field with any interest, you will note that investigative tests of hearing ability are insufficient to adequately define the nature, extent, and impact of hearing loss.  Without better information, treatment that doesn’t involve surgery or a cochlear implant is not very predictable and sometimes not sufficient for many patients.

Some clinicians complain that investigative testing is not adequately profitable, and that the sale of devices is the sole manner in which audiologists can sustain the field.  Even ENT offices argue to support this view. 

Some of these folks have little equipment but do drive nice cars.  They claim there is insufficient data supporting the use of best practice tests. 

I recall the same comments about many clinical procedures just prior to the arrival of their proof of value.  Many of those measures have worked out pretty well reimbursement-wise.




If we stop moving forward and cease to develop, prove, and use our tools, our field will morph into something it was not intended to be.  We wish for widely recognized clinical relevance but without forward movement in both investigative tests as well as with data driven treatments, we will enjoy less than limited clinical relevance. 

With a little thought, the advent of all the coming changes in retail audiology may prove to be opportunities and not impediments.  For example, PSAPs may offer a tool for change in predicting benefits of amplification.  Easy access to simple devices may increase the need for defining tests of predictive outcomes or methods to help if these devices fail to “fix things”.  Patient dissatisfaction with simple devices may inspire more peer-reviewed proof of higher technology. 

As someone’s grandfather probably said: “When one door closes, another opens.”  Maybe we can learn from the past.


feature image from Russpod