Anecdotes from the Past

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

About Mike Metz

Mike Metz, PhD, has been a practicing audiologist for over 45 years, having taught in several university settings and, in partnership with Bob Sandlin, provided continuing education for audiology and dispensing in California. 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.