Ethics versus Reimbursements-Part 1

by Mike Metz


A renowned and respected otologist told me over 25 years ago that if I was not billing insurers with the “unlisted procedure” code (a “by report” code for reimbursement), I was not on the leading edge of my profession.   Good advice at a time when the field was moving forward.

Not like these days.

In a private audiology office, what are the consequences if a clinician does not adhere to best clinical practices because tests are not reimbursed sufficiently?  Does he/she proceed with necessary procedures knowing they won’t be paid?  Does it make a difference if the patient is covered by a “conventional” insurance plan (balance billing?) versus a Medicare plan?

In an audiology office, with patients seen for investigative testing upon referral, the assumption is that neither a history nor a report is necessary, as these tasks fall back to the referring physician.  Hence, the billing allowed the audiologist consists of only a “technical” fee, and these are pretty low.

If the physician refers for complete diagnostic testing within the scope of audiology, a series of within-scope-of-practice tests are in order, the methods and interpretation of which may not have been “in the book” of most physicians.  In these cases, a review, an addition to the history, and a report are necessary for proper management of the patient’s audio/vestibular problem.  Many tasks associated with the procedures are not reimbursable (irrespective of value).

On May 5th of this year, Barry Freeman posted a treatise about professional concerns on the Audiology Academy website discussion board.  Of particular interest was his discussion of the Ethics of Weakness and audiology functioning from that stance.  He concludes by saying,

Are we suffering from an ethics of weakness?  I certainly hope not but certainly the reports coming out of DC from groups like the IOM and PCAST are questioning the entire hearing care delivery system. Let’s prove to those that are watching us that we can make decisions that are in the best interests of our profession and people we serve.

What proof is required?

When issues of reimbursement conflict with professional ethics, which prevails: the professional scope or the legally expedient regulation?

The tragic answer is that the regulation won.  Audiology was ineffective in the efforts needed to change this.  Barry is correct. Audiologists and their organizations apparently decided that they could make up for the lack of reimbursable tests by abandoning the ethical practice stance and/or by bundling a few tests into the sale of hearing aids. In essence, the easier path was taken and investigative testing gave way to tossing a couple of quick diagnostic tests into a sales pitch. Physician offices like this system.  Dispensing audiologists like it too.

When called upon in court to defend audiologists who did not do all the tests necessary to fulfill their duty to a patient, the most successful argument has been that the audiologist was not legally qualified to make a diagnosis and therefore not really accountable for subsequent patient problems.  And that disqualification negates any audiology scope of practice.  It also disallows for responsibility to the patient, despite any degree or ethical code.

Audiologists did not pay sufficient attention to their scope of practice, specifically in terms of using tests that more specifically define problems, and then pursuing the tasks necessary to create sufficient justification and reimbursement.  If there is value in the hearing clinic, there is a need to assure a rational as well as a financial base for this value.  Now the field faces huge problems in that most investigative tests do not generate the level of reimbursement necessary for the maintenance of a professional practice.  Without device sales, there appears to be insufficient value in differential testing, to say nothing about rehabilitative procedures.

At this time in the short history of audiology, private practice is left with only retail sales to support its financial self.  Such cannot be the sole driver of future professional independence.

If healthcare’s primary responsibility is to the patient, and if this responsibility is dictated to a large degree by a scope of practice, the direction is obvious.  If regulations and billing restrictions prevail, then audiology can look forward to a future in which most financial reward comes not from professional abilities, but only from retail sales.

I think this dilemma and its side issues pose the largest problems to the profession.  And it seems to me that if audiology is to remain anything other than a retail source for hearing devices, its resolution should be at the top of the to-do list.

If you think that looking for help in these matters from other health professions will save us, see Part 2 to follow.


Michael Metz, PhD
Michael Metz, PhD

Dr. Metz has been a practicing audiologist for over 45 years, having taught in several university settings and,  in partnership with Bob Sandlin, providing continuing education for audiology and dispensing in California for over 3 decades.  Mike owned and operated a private practice in Southern California for over 30 years.  He has been professionally active in such areas as electric response testing, hearing conservation, hearing aid dispensing, and legal/ethical issues.  He continues to practice in a limited manner in Irvine, California.

About Gael Hannan

Gael Hannan is a writer, speaker and advocate on hearing loss issues. In addition to her weekly blog for, which has an international following, Gael wrote the acclaimed book "The Way I Hear It: A Life with Hearing Loss". She is regularly invited to present her uniquely humorous and insightful work to appreciative audiences around the world. Gael has received many awards for her work, which includes advocacy for a more inclusive society for people with hearing loss. She lives with her husband on Vancouver Island, British Columbia, Canada.