Is AAA Thwarting Efforts for Audiologists to Obtain Professional Autonomy, as Some Claim?

August 1, 2018

The American Academy of Audiology (AAA) is, by far, the largest professional organization in Audiology, but the much smaller Academy of Doctors of Audiology (ADA) is gaining members at a record pace. According to ADA, the group has gained more than 120 new members this year. A probable cause of this sudden growth in ADA membership is a schism between AAA leadership and some of its rank & file members over support of the Audiology Patient Choice Act (APCA) of 2018. A prickly issue, often pitting members of both professional organizations against each other, which has been, under various forms, in Congress’ legislative pipeline for several years.

Recall that the latest iteration of APCA bill, introduced in Congress earlier this year, is to remove the requirement that Medicare recipients must receive authorization from a physician prior to seeing an audiologist for a hearing evaluation. Today for an audiologist to receive Medicare reimbursement the hearing evaluation must be “ordered” by a physician who also charges Medicare for an office visit. This extra visit with a physician is widely believed to increase the cost of care to the taxpayer-funded Medicare program.

Currently, approximately 44 million Americans, some 15% of the population rely on Medicare for their healthcare coverage. That number is expected to markedly rise over the next decade as the Baby-boomer population ages. Given the average age of Medicare recipients is well over 65 years, a high percentage of them have hearing loss and likely could benefit from direct access to hearing care provided by audiologists.


Endorsement of the Audiology Patient Choice Act


The bill, HR 2276/S.2575, has been endorsed by the Academy of Doctors of Audiology, but AAA did not provide an endorsement of the legislation. The American Academy of Audiology did agree, however, to not actively oppose the direct access bill. Given the size of AAA membership, this equivocating position is tantamount to opposing it, according to several AAA members HHTM contacted. (The bill, unsurprisingly, is strongly opposed by the American Academy of Otolaryngology, although some individual AAO members do support the bill).

To understand the frustration of some AAA members, it helps to recount the events at their recent meeting in Nashville. Soon after the annual meeting of the American Academy of Audiology in April, in which reports suggested contentiousness among members about AAA’s stance on the American Patient Choice Act, the AAA’s leadership posted this detailed FAQ to address the issues surrounding the APCA. Shortly after AAA posted their FAQ, the Academy of Doctors of Audiology, fervent supporters of the current APCA legislation, issued a detailed brief that addressed several questions concerning AAA’s FAQ document on the bill.

Although AAA was founded more than 30 years ago on the principle that Audiology be an independent doctoral-level profession, the organization –  more than four months after their contentious membership meeting in April – continues to have concerns about the current bill, which has frustrated many of their members.

Audiologists in favor of the legislation believe the potential to lower Medicare costs for the most expensive healthcare system in the world and improve access to care – the intended benefits of the bill, outweigh the risks associated with its passage. In addition, many supporters cite that directly billing Medicare for hearing testing is fully within their scope of practice and results in superior care because patients without medical contraindications on their test or case history do not have to make an unnecessary appointment with a physician.  

Although HHTM could find no one willing to speak out in opposition to the bill, according to the FAQ on the AAA website, those wary of the APCA legislation point out audiologists may have difficulty opting out of the direct billing of Medicare. In addition, there are concerns that Medicare wouldn’t reimburse for a full range of benefits, including evaluation and management (E/M) services, not just hearing evaluations. Beyond those reasons, which are posted on their website’s FAQ sheet, it is difficult to know why some members are wary of the bill because HHTM could find no audiologists willing to go on the record opposing it.


Members Weigh In


Several AAA members were queried by HHTM and for those willing to express their opinion, support for the APCA was unanimous.

As one member, Sheri Gostomelsky, an Illinois audiologist told HHTM,

“The APCA is the only way to move Audiology forward.  If our profession is to survive and grow roots, we need to change. Direct access, billing for what we are licensed and trained to do and changing our taxonomy within the Medicare system is vital to the future of Audiology. I don’t understand why AAA will not back the complete act and look at the big picture.  We should be allowed to bill and be reimbursed for services that are already recognized by Medicare and fall within our scope of practice.”

While there is evidence suggesting audiologists (most of which now have a doctoral degree) possess ample training to diagnose and treat most hearing and balance problems  — and know when to make a necessary referral to a physician when indicated by test results, patient symptoms or case history — several AAA members were rankled by what they perceive to be AAA’s seemingly inchoate position on the APCA bill.

According to a press release posted on their website, AAA has not taken a position, and, instead, is doing “due diligence” by asking for the opinion of members and listening.  However, of the more than a dozen AAA members contacted by HHTM, it is reasonable to conclude that the APCA bill is supported, often enthusiastically, by many rank and file members.

“Currently I am an active member of all three organizations so I have contacted AAA and ASHA about my disappointment in their choices and lack of support, although we all know that didn’t change their minds,” said Stacey M. Baldwin, an audiologist in Overland Park, Kansas. “I am thrilled to say that more than half of the state AAA chapters have already formally endorsed APCA and we are starting to pick up more ASHA chapters, too.”

Other audiologists were even more blunt in their assessment of AAA’s handling of the APCA.

Colorado audiologist Julie Link shared:

My support for the APCA is simple. Even in just 4 years of practicing, I have consistently observed that my patients who receive early diagnosis and treatment are the most happy and satisfied patients. These are the patients who stick with their treatment plans because they can actually appreciate the improvements. Drs. Campbell’s and Sharma’s 2016 research1 regarding the cross-modal re-organization in adults with early stage hearing loss could lead one to argue that the delay in access to care is actually a safety risk to our patients. There are already so many barriers to timely audiologic care for our patients (stigma, financial, transportation, misinformation, etc.), they do not need one more barrier to keep them from getting the audiologic services that they need.

With LLP status, comes new responsibilities. I believe that AAA is concerned that audiologists will not be properly educated for this new role and they themselves do not feel confident that they can provide the proper education to their members. If dentists, optometrists, and chiropractors can be prepared for these responsibilities in a 4-year degree, so can we.”

  1. Campbell J, Sharma A. Cross-modal re-organization in adults with early stage hearing loss. PLoS ONE. 2014; 9(2): e90594. doi:10.1371/journal.pone.0090594.

Private practice audiologist, Cliff Olson, owner of Applied Hearing in Anthem, Arizona, also weighed in on the issue:

“I’ve been an audiologist for only two years and within that time, we are already on our second piece of critical legislation that could have a massive impact on the future of our profession.  I support the APCA act for two reasons. First, it clearly benefits patients with Medicare by allowing direct access to audiologic care. Second, Limited License Physician status will be an advancement of the profession, and I believe that if we are not growing as a profession, we are dying. It’s about time that we achieve professional parity with other doctoring professions and are allowed to function within the full capacity of our state mandated scope of practice.”

Another audiologist and AAA member who expressed unwavering support for the APCA is Sam Vaught, a practice owner in Georgia:

“I am, and always have been, very passionate about supporting direct access legislation every time it has been introduced in the U.S. Congress.  I am supporting the APCA because it is time that CMS recognizes audiologists as an entry point into hearing healthcare. Our profession has evolved since its inception and CMS simply has not kept pace with our state licensure laws and our change in scope of practice as we have become doctoring professionals.  There really is no need for a physician referral and that is evidenced by the Federal Employee Health Benefits Program and Medicare Advantage plans that do not require a physician referral. It would save CMS millions of dollars by eliminating the office visit to a physician for a referral (unless a patient prefers to see an M.D. first).  While the APCA does not change our scope of practice, it would allow us to perform some treatment procedures on patients instead of having to refer them to another professional who can bill CMS for the same procedure, and it is much more convenient for the patient not to have to make another appointment somewhere else! And it would recognize us as the doctoring profession that we are for CMS purposes along with the other non-physician doctoring professions.  These are three very legitimate reasons that I support the APCA and so should AAA.”

Other AAA members who support the APCA expressed astonishment that AAA leadership also wavered on pending over-the-counter (OTC) hearing aid legislation. They point to the Academy’s statement on OTC devices, posted on their website, which seems to offer tepid support of OTC devices, but falls short of endorsing current OTC legislation.

The AAA members HHTM spoke to expressed concern that AAA is vacillating on pending regulatory changes that are important to the future of the profession. The Academy’s OTC statement is available here.


Audiology & LLP Status


Opinion leaders within the field like to compare Audiology to other similar professions such Optometry and Dentistry, which both have Limited License Physician (LLP) status and the ability to directly bill Medicare patients. An HHTM query of a handful of dentists and optometrists, however, suggests that neither profession is willing to relinquish their LLP status because it helps reduce barriers for patients in need of their services and enhances their professional autonomy.

Another important constituency with a huge stake in issues related to professional autonomy are students and those who have recently graduated. Many of these students and newly minted Doctors of Audiology are expected to graduate with a significant amount of student loan debt, sometimes more than $100,000. Yet audiology remains one of the lowest paid doctoral level professions, according to data presented at the April 2018 AAA membership meeting.

Direct access to Medicare patients is believed by some to play a role in improving the compensation of audiologists.

Although several students have voiced their support of the APCA, the American Academy of Audiology recently reminded ADA that the Student Academy of Audiology, which is an official organization of AAA, cannot independently endorse the bill per a recent correspondence from Amy Miedema, Vice President of Communication and Membership for AAA.  

For more on student loan debt in audiology, see this recent HHTM Hearing Economics post.


Unintended Consequences?


Like any piece of US Congressional legislation, there is expected to be some unintended consequences resulting from its implementation. And, a careful reading of AAA’s FAQs “Regarding the Academy’s Position on the Audiology Patient Choice Act” suggests their leadership is indeed concerned some unintended consequences will result from the legislation. Beyond their posted FAQ on the subject, however, AAA leadership is opaque about their uncertainty towards the APCA bill.  This statement is based on HHTM’s attempt to reach AAA leadership for comment. As of July 28, queries to AAA leadership by HHTM have gone unanswered.

Although academy leadership does not endorse the APCA, on July 17, AAA posted on its social media accounts endorsement of the Medicare Telehealth Parity Act of 2017. It is an act that identifies audiologists as appropriate providers of telehealth services and authorizes Medicare to reimburse them for providing patients with audiology services via telehealth.


*Disclosure: Brian Taylor is a member of AAA and is the editor of ADA’s Audiology Practices publication.

birdsong hearing benefits
  1. Many audiologists are not experienced or knowledgeable about legislative advocacy, especially in the area of health-care legislation. They may not know the history of other legislative initiatives. For example, a prior iteration of the patient choice act (one that did not include LLP status) was promoted by AAA for a number of years. Be clear, legislative advocacy means spending money to get congressional support. How much of a members dues (plus other volunteer contributions) are people willing to pay to support this effort? It could run the coffers dry very quickly, and without much to show for it. Your op-ed downplays these costs as well as the unintended consequences of LLP status. There are political and practical realities, and very real (and costly) consequences.

    1. Please Dr. Cone, explain these unintended consequences of LLP? If it is so heinous, why are optometrists, chiropractors and podiatrists happy with their status and why is psychology, OT and PT pursuing it? Please share your thoughts rather than just throwing stones at something. What about compromise? I have always been open to hearing it? Has ASHA or AAA ever offered it? The answer is no. I only hear crickets. ASHA is instead committed to Audiology being perpetually dictated by medicine, even though this oversight does not exist in the private sector or in licensure.

  2. I think its time for audiologists to shed their cloak of superiority and hypocrisy, and begin to focus more on improving hearing and the lives of the hearing impaired people. We both have noble tasks to accomplish daily. There is no form of reimbursement available to HAD’s like me, and yet I outperform most audiologists in the daily functions of hearing aid fittings and adjustments.

    We dispensers have no access to political influences and no degrees to flash around to make us feel equal in professional endeavors.Politics and Greed are now commonplace among audiologists. What a shame on our profession!

  3. Lets face it: insurance is here to stay. When patients ask, “do you take Medicare”? The ONLY good response is “yes” or they hang up. The so-called physician referral is nonsense because most patient need amplification not medication. For AAA to oppose this is an assanine as thinking OTC hearing aids will bring new patients in droves. Where do these audiologists get there information-in a cereal box coupon? There is a real world out there and the audiologists version of reality. If we can’t control our future we will not be a part of it.

    1. Good post Dr.Brady. Physicians are very reluctant to provide referrals for hearing aids because they consider that to be a non medical issue.I agree that OTC aids may have a marginal impact on the new wearers. Also, lack of rehabilitative responses will disappoint many of them, because they will still be in a “shopping mentality”. Hearing rehab is an absolute must and with an audiologist/HAD. So we need to apply pressure on fly by night operators peddling bogus hearing aids to back off from trying to get a share of the pie! Now we hear that Silicon Valley wants to get into this business.

  4. Maybe this should be titled “is ADA undermining the private practice audiologist”. After all it is ADA, not AAA or ASHA that gave their full-throated endorsement of the OTC HA bill. I would recommend that any audiologist, especially those in private practice should think twice about supporting anything that ADA is throwing their weight behind.

    1. You have a point, Gabe. Although, in fairness, I think ADA saw the writing on the wall that OTC was coming whether we liked it or not.

      I’m not an ADA member, but have been one of AAA’s for over a decade. Honestly, much of this harkens back to the push for the AuD as the entry-level degree into audiology. We bought all the promises, hook, line and sinker. I blame both ADA and AAA for that. Now we have come to a cross-roads where our scope hasn’t changed in 20+yrs, plus we’re not only graduating fewer audiologists–our new grads are coming out with very high salary hopes in order to pay off their tremendous loan debt they’ve just incurred to become a “doctor”.

      As I see it, the collapse of APCA–or continued lack of support for it–is an absolute repudiation of the AuD. If we REALLY want to be the doctoring profession we all claim we want, then we have to pass some version of this bill. I’d love the LLP status, but I’d settle for Direct Access.

      OTC was a shot across the bow–it’s time to pull our heads out of the sand. Hearing aids will not support the profession long term, so how are audiologists going to sustain themselves? If we don’t pass some version of this bill, I’m afraid audiology will go the way of the Dodo and will cease to be found outside of the VA and academia in the next 20 years.

  5. Hi Brian,

    To clarify, the 18×18 legislation/APCA doesn’t address professional autonomy. Also, the assertion that a professional organization composed of audiologists, and which is lead by a volunteer board of those same audiologists, would in anyway thwart professional autonomy is absurd. The 18×18 legislation addresses accessibility to services and CMS payment policy. Audiologists already have professional autonomy. We aren’t required to have any level of supervision to perform any of the services within our Scope of Practice (SOP). This is dictated by our state licensure.

    The direct access piece of this legislation would reduce unnecessary physician visits that can be a barrier to Medicare eligible patients receiving services. I contend the other aspects of this legislation has the potential for very serious consequences for audiologists and the patients we serve. I understand that other non-physician providers have limited license status in the Medicare statute; however, chiropractors perform only one service covered by Medicare and dental services are limited to surgical procedures, primarily paid for by Part A hospital services. To expand the scope of Audiology services covered by Medicare, with a flawed system that determines the value of those services, and no option for audiologists to opt out, could be detrimental to our profession. More importantly, this could be devastating to the patients who need our services. We can only provide those services if we remain in business.

    There are more questions to be answered regarding what steps the profession should take to address issues with CMS payment policy. In my opinion, the profession is often like the round peg trying to be fit in the square whole of CMS policy. I appreciate that my colleagues serving in leadership roles in the AAA are trying to educate these agencies, meeting with CMS administrators and working to answer these tough questions. As the profession has matured, we learn more and are better able to base decisions on evidence rather than emotion. A question we should be asking our colleagues is could they maintain their practices or the staff at their facilities should many of the services we provide be covered by a system that undervalues those services. We’ve seen a reduction in CMS payments for more than a decade, do we really want to entrench the profession into this system even more?

    I hope our profession can turn this narrative from a negative to a positive one. We can do so much more working together to advance the profession.

    Respectfully and in full disclosure,

    Erin L. Miller, Au.D.
    Past President, American Academy of Audiology

    1. What makes it absurd? There is a great deal of evidence, both subjective and objective, of AAA advocating against this initiative. You say you care about patients but seem to be opposed to the coverage of medically necessary rehabilitation or treatment? Why? AAA has spent lots of time throwing darts at the APCA. Do they have a compromise position or compromise language? Can they clearly and consistently articulate their position? Does AAA have a plan of their own? The answer on every front has been “no”. AAA has no plan or compromise. They just have “darts” and misinformation. On all of the biggest issues affecting Audiology, AAA is always “neutral”! Why don’t you really try to work with others to accomplish something great that helps patients and the profession, rather than just AAA?

      1. I appreciate you have a different perspective Kim, but to make an assertion that this group of volunteer leaders who represent the profession of audiology are trying to “thwart” autonomy is absurd in my opinion. This was my post and my opinion. Perhaps more importantly, this legislation isn’t about autonomy. You can choose to disagree, and I respect that, but I don’t see that same respect given to myself or others who have a different opinion. Every post I have seen appears to be an attack when someone doesn’t agree with your position. I can’t speak directly for the leadership of AAA as I no longer sit on the BoDs. I do however continue to volunteer for the organization and I have been very pleased with the information they have gathered and continue to compile to determine what the best course of action may be for our profession. Perhaps a legislative initiative, certainly further educating regulatory agencies about the value of our services, there is likely more than one option. I see the efforts the AAA has made as doing their due diligence to obtain the necessary information in order to make an informed decision for our profession in 2018. You can’t speak for AAA’s plans either, as much must happen behind the scenes before an announcement is made. This 18×18 legislation wasn’t introduced by ADA in 2013 without work going on behind the scenes first. Also, your recollection of working with others for a compromise appears a bit skewed. There was work to try to come to a consensus on a single legislative initiative for several years, meetings with a facilitator and much discussion. This was all relayed to the memberships of AAA, ADA and ASHA during that period. In the end no association, and that includes ADA, was willing to compromise. What the Academy did in 2014 was decide not to reintroduce the singularly focused direct access legislation. Rather, they decided to spend their resources on regulatory initiatives and support of other legislative initiatives that would impact the profession. Finally, I would agree with having all services within our SOP covered by Medicare, but what happens when those services increase in utilization (which they will) and are revalued through the RUC process? I’m sure the sponsors of this bill can’t provide any assurance that this won’t happen. Audiologists are better educated and skilled to provide these services but we can’t do that if we can’t keep our doors open! There has been a 25% reduction in reimbursement of our diagnostic services over the past decade. To me this is about doing what’s best for our patients…if we can’t remain viable where will the patients go? I understand you see this differently and are willing to roll the dice. I’d rather not, as the evidence to date doesn’t suggest that will help patients or our colleagues. I believe there are other ways to manage affordable services for our patients currently within the purview of each facility or practice owner. We’ve seen the trend toward unbundled services and I applaud those efforts. Please don’t misrepresent what I said in my response.

        1. This is my final reply to Dr. Miller on this issue. First, “respect” too is a matter of opinion. Respect is earned through transparency and honesty. As a result, I feel as though I and many other audiologists have been continually disrespected by you, many other AAA volunteers and AAA leadership. Second, I am not sure what meeting you were at in 2014 but no compromise from any party was put on the table to reject. Please do not misrepresent the facts. Also, it should be noted that in 2014, AAA was supporting the Audiology Patient Choice Act. Finally, I ask how is sitting on your hands and doing nothing working within the RUC process? Are codes not being resurveyed? Is your allowable rate increasing? Are you providing greater access to patients? Are you increasing audiology’s role in Medicare? I so desperately want there to be a large, strong national audiology association. Folks are trying to throw AAA a life preserver but the crew onboard are bound a determined to stay the course. I just hope the “crew” doesn’t sink the ship!

    2. Dr. Miller, I find your comments fascinating. Here you state: “The direct access piece of this legislation would reduce unnecessary physician visits that can be a barrier to Medicare eligible patients receiving services. I contend the other aspects of this legislation has the potential for very serious consequences for audiologists and the patients we serve.”

      However on October 27, 2014, you penned a letter of endorsement (as AAA President) that stated: “As stated in prior communication with you and your board, the Academy fully supports efforts toward physician status for audiologists as this has been a long range goal of the Academy since its inception.”

      I am confused as to how the exact same legislation could be consistent with AAA’s long range goals in 2014 and have your stated support through two Congresses, but now pose “very serious consequences”.

      I look forward to your explanation.

      All the best,
      Brian Urban, AuD
      Past President, ADA

Leave a Reply