Medicare, Billing and Free Tests

If you are a Medicare Provider do you and your staff know the rules you have to follow for Medicare?  If you are a patient, why will some places give you a “free” test and others will not?  Answering these answers requires covering a lot of ground.

What prompted these questions was a class I taught concerning insurance in “Business in Audiology” at the University of Arizona and a new article from the American Academy of Audiology addressing the question of whether or not offices can send out reminder cards (their answer: probably not).

I have touched on Insurance issues, previously addressing the pros and cons of being a provider for certain insurances.  This current blog is focused solely on Medicare, with which all providers must enroll in order to acquire National Provider Identification (NPI) numbers, without which they cannot sign up with other insurance providers.  The place to learn about being a provider is the Centers for Medicare and Medicaid Services’ CMS website.  Participating providers must agree to the rules and accept whatever Medicare part B will allows for the services provided.  NON participating provider decline the Medicare assignment agreement  covered services and receive 5% less than a participating provider.  The catch here is Audiologists are not included on the list of providers who are allowed to opt out of Medicare, so for Audiologists, it is all or nothing.

When you are a participating provider, you must have a  referral from the physician that pertains to a medically reasonable and necessary condition and NOT for the purpose of fitting or modifying hearing aids.  Medically acceptable reasons for referral center on specific medical concerns related to medical conditions that can affect hearing, to patient reports at onset and/or changes in hearing loss, tinnitus and/or dizziness.  If the referring physician orders the test for the specific purpose of fitting or modifying a hearing aid, payment for the exam is not allowed.  Paraphrased from the AAA article,

Payment for audiological diagnostic tests is allowed for other reasons which may include, but are not limited to:

• Confirmation of a prior diagnosis;
• Post-evaluation diagnoses;
• Treatment provided after diagnosis, even if the diagnosis resulted in fitting of hearing aids;
• The type of evaluation or treatment the physician anticipates before the diagnostic test;
•  Re-evaluation at a schedule dictated by the ordering physician when the information provided by the diagnostic test is required, for example, to determine changes in hearing, to evaluate the appropriate medical or surgical treatment or evaluate the results of treatment.

As an example, re-evaluation may be appropriate, even when the evaluation was recent, in cases where the hearing loss, balance or tinnitus may be progressive or fluctuating, the patient or caregiver complains of new symptoms, or treatment (such as medication or surgery) may have changed the patient’s audiological condition with or without awareness by the patient.

The AAA website and the interpretation of the CMS site make it clear that if you are a Medicare provider it is a violation of Medicare rules and regulations to provide a free hearing exam, even if only to evaluate and fit hearing aids.  It is prohibited by Medicare to give a free test as an inducement to generate other services. Clear or not, this leads to confusion among consumers and patients we are trying to help.  We frequently hear those people complain that

“The office down the street gives free hearing tests!”

How frustrating to tell the person

“As a Medicare provider I can not give a free hearing exam. But, you do not have a medical necessity for which your physician can refer you for a Medicare-covered diagnostic test.  You will have to pay $$ for this exam.”

At such times Audiology providers find themselves between a rock and a hard place.  On the other hand, we feel justified to charge, even if only a small amount, for diagnostic services because we are using our knowledge and expertise to determine what is wrong with the person’s hearing and how best to help them.  Many providers firmly believe that their years of experience alone should count toward the small price of an exam.

The debate in an old one that goes on unabated.  It is complicated by non-Medicare providers with state licensed to test for the purpose of hearing aid fitting; by other insurance companies that eliminate Audiology entirely by going directly to the primary physicians.  But those topics are for other blogs!