Editor’s Note: This week, we have a contribution from Alyssa Fischer. Alyssa is a third year AuD student at UNC Chapel Hill, and has spent the last few months in our vestibular lab at Wake Forest. Her perspective is unique in that her mother and brother are both audiologists, so she has some insight into the fact that there are financial realities to consider when deciding to go into our profession.
The Value of Audiology- A Student Perspective
by Alyssa Fischer, B.S.
From linguistics to anatomy, auditory perception to aural rehabilitation, there is not one topic about the ears that I have not covered as a third year Au.D. student. But when it comes to the value of the profession I have been pursuing for the last seven years, there is a lot that a textbook cannot teach me. I am talking about how Audiology procedures are reimbursed, how our profession is viewed by insurance companies, and why the patients we want to help are denied coverage for services and devices that are proven to better the quality of their lives.
I have spent over two years rotating through five different Audiology clinics and learning from fifteen different clinicians, so it is a surprise that information regarding reimbursement of our services was neglected to be shared. In fact, clinicians are not to blame since many of them do not have a role in determining cost.
I recently did a presentation on the Current Procedural Terminology coding system–the codes that we use in Audiology to bill our services to Medicare, and I learned that my peers as well as my professors knew very little about the reimbursement values of our services. Because of this, I want to shed some light on this process that affects the 14,000 Audiologists and the forty-eight million people with hearing loss in the United States. For this post, I will take you through a few key points and highlight some of the questions that I asked when doing my own research.
Before we jump in, I will briefly mention that I focused my searches on adult Audiology outpatient clinics. With approximately 25% of adults older than sixty-five years old and 50% of adults over seventy-five years old affected by hearing loss, it’s no surprise that Audiology clinics primarily bill through Medicare Part B. Medicare Part B is for outpatient services and adheres to the Physician Fee schedule that is published annually by the Center for Medicare and Medicaid Services. With such a large portion of the elderly population being affected by hearing loss, it’s important to recognize this close relationship between Medicare and Audiology services.
Fee Schedules for Audiology Services
The first piece of information that is important to understanding the value of Audiology is that insurance companies tell us how much our procedures and services cost.
Let’s think about the Current Procedural Coding System, also known as CPT Codes. This is the coding system that is used to describe tests or evaluations performed by a healthcare provider and is the most important for Audiology reimbursement of services. CPT Codes are developed and maintained by the American Medical Association (AMA), and the Center for Medicare and Medicaid Services (CMS) approves and publishes the reimbursement value of these codes. After an almost 2 year-long process of creating a recommended value for an audiology service, CMS has the final say on maximum fees for services. In other words, Medicare tells Audiologists how much Audiologists can charge for services and procedures.
Let’s look at an example:
CMS published in the Proposed 2021 Physician Fee Schedule that a comprehensive audiogram fee maximum is $35.81. This means an audiologist can only be reimbursed the maximum of $35.81 for that service. If an Audiologist tries to bill a Medicare patient more than the maximum, then only $35.81 will be collected. An audiologist cannot charge a patient privately for a service that Medicare would have covered, and if a service is provided free to one patient, it must be provided free to all patients regardless of how they pay.
When I asked a group of Audiology students how much a comprehensive hearing exam is valued by Medicare, they estimated between sixty and a hundred dollars. These students estimated this cost based on the time it takes to do the exam, the education towards performing and interpreting the exam, and the cost of the equipment. One can imagine how surprised these students were to find out how much less the reimbursement values their services actually are. What was not surprising though, was how they came up with their estimated values. Similarly, the recommended reimbursement value is constructed with thought by the AMA.
The Relative Value Scale update committee within the AMA creates these recommended values from two categories– Time and Value.
- Time includes “pre-time”– the time it takes to register the patient, review the patient’s chart, and get them into your exam room, “intra time”– the time it takes to do the procedure, and “post-time”– the time to counsel the patient and write the report.
- Value encompasses “work value”– the knowledge and education required to do the procedure, “practice expense”– how much it costs the clinician to provide the service, and “liability”– how risky the procedure is.
It’s great that so much thought goes into this recommended value, but what kind of representation does Audiology have in the American Medical Association?
Within the AMA is a committee called the Health Care Professionals Advisory Committee. This group represents the Allied Health Sciences which includes professions such as Audiology, Speech Language Pathology, Occupational Therapy, Physical Therapy, etc. Within this committee, Audiology holds one seat.
The AMA also embodies the Relative Value Scale update committee, which mentioned previously, creates the recommended reimbursement value of procedural codes. This committee includes one person from the Health Care Professionals Advisory Committee. That’s ONE person representing all of the Allied Health Sciences on the committee that recommends the value of our procedures.
Audiologists are also given the opportunity to influence this recommended value. When a code is being valued by Relative Value Upscale Committee, a survey is sent out to a sample of clinicians. These surveys collect information about the procedure such as who does the procedure, how much time the procedure takes, and how much skill is needed. The survey is issued to professions who have an interest in the code. For codes regarding hearing services, otolaryngologists and otologists may also receive these surveys, and for vestibular codes, neurologists may be included.
With so much time, thought, and effort that goes into creating a procedural code and value, it’s disappointing how low our audiology fee maximums are.
While I do not have an understanding for why my four-year doctoral degree receives a work value that is relative to that of a technician, I do know that new Physician Fee Schedules will continue to have a negative impact on Audiology.
The estimated overall impact of the 2021 Proposed Physician Fee Schedule on Audiology is -7%.
Why are the value of our procedures and services being negatively impacted?
Because of many factors such as inflation, the neutrality of Medicare’s budget, and fraud that occurs when a code is overused or misused, the maximum value that CMS gives our services decreases annually.
If our services are decreasing, how do Audiologists afford to keep their practices open?
When I first read through a Physician Fee Schedule, I was surprised to see that not every Audiology service has a procedural code. I quickly learned that not having a procedural code for everything can be a good thing.
Without a fee maximum determined by CMS, Audiologists can charge patients what they believe is fair for their services. Unfortunately, since most Audiology procedures have a determined fee maximum, many practices must rely on hearing aids sales for revenue.
As many of us know, Medicare does not cover services related to hearing aids including prescribing, fitting, programming, or examining hearing devices. While hearing aid sales and services keep Audiology clinics open, the lack of insurance coverage prevents many patients affected by hearing loss from seeking professional help. According to Hearing Loss Association of America, only one in five people who would benefit from a hearing aid actually use one.
As Audiologists, we know our value.
It is important for Audiologists to be honest in our practice and recognize our true value. Audiologists should continue to perform services on patients that are required and to provide patients with the best care possible. We should continue to use procedures that are supported by evidence in research.
Audiologists must get involved with professional organizations, reach out to our legislators and work with our state lobbyists to keep the future of our field bright and accessible to our patients and future audiologists like myself.
Though I recently learned of the unfavorable value that Audiology may have, I have not once regretted my choice of pursuing an Audiology degree. I grew up with Audiologists in my family, and I can easily say that I have never met an Audiologist in my lifetime who is not passionate about helping those with communication needs.
It’s clear that Audiologists do not pursue doctoral degrees to become salespeople or technicians. Rather, audiologists join this field to better the lives of those affected by hearing loss, balance disorders, and tinnitus. I will leave you with a few quotes from my enthusiastic peers currently pursuing Au.Ds:
- “Communication is one of the most important things in our lives, and by supporting hearing, audiologists support patients in living their best lives.”
- “I want to help amplify the voices of the hearing loss community and provide the best resources and support that I can”.
- “I value helping people express themselves and interact with those around them”.
- “It is truly amazing how technology can help individuals achieve their communication goals, fostering independence and self-confidence through the gift of sound.”
Special thanks to Dr. Alan Desmond for enlightening me with this very important topic related to Audiology.
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