The decision to become a participating provider is not as easy as you think. We have seen managed care change dramatically over the past 20 years. Even though hearing health care and hearing aids were often value-added discount items rather than covered benefits, it helped having the office or audiologist/dispenser’s name in the providers directory for referrals alone. In Arizona, we are seeing more Insurance companies use hearing benefits as a carrot to get people to sign on with their plans. The practice has grown beyond Medicare Advantage programs appealing to senior; now we are seeing it with giant healthcare companies appealing to potential members of all ages.
Having a knowledgeable, even-tempered office staff person deal with insurance from the moment the patient calls for the first appointment helps. It is best to be prepared and get the insurer’s name, group number, ID number and provider number on the back of the card at the initial phone call for the first appointment. Over the past several years, more national hearing specialty independent provider groups, such as EPIC, have negotiated contracts with major insurance companies, especially United HealthCare. The negotiated benefits vary from contract to contract.
We, the providers, have to know what the benefits are and how they are handled before we see the patient. With these contracts, the provider may have to call for a price of a hearing aid while the patient is in for the consultation. In some contracts, the negotiated price allows balance billing over and above the instrument benefit; others require the provider to sign an affidavit that they will not balance bill. After approval, which can take days, the provider can fit the patient and is paid a fitting fee. Some of the fees are so low–practically an insult considering the time required to fit properly– but others are very reasonable. It is up to provider to assess the different negotiated contracts and determine whether it is in the practice’s best interest to sign up or not.
I realize everyone needs to save money where they can and we extend ourselves as much as possible to accommodate patients with different contracted insurance benefits for our services and products. This approach has increased my offices’ time on the phone finding out specific benefits, time at the appointment because we do not know the price, and time for fitting because we have to wait for approval. We normally can fit same day with certain technology, but not with this new set up.
The last struggle is what to do when your office’s prices are significantly lower than the national third party contract holder. It can be a few hundred dollars to over a thousand. If this is the case, your office could 1) raise their prices to more closely match 2) keep your pricing the same as long as you are covering all of your over head costs and you will have great word of mouth for having great competitive pricing and great service for those who do not use this particular third party contract holder or 3) keep your pricing, have patients buy directly from you and run the risk of loosing your contract because you are undercutting your contract (I do not advise this as it is unethical and can lead to many problems some possibly getting sued!). In my opinion, the private practice must have listed pricing from the third party contract holders so the same retail pricing range can be used and no one “takes” hearing aid sales from other referral sources.
Should we be participating providers? Some say yes, to help the patient get the best possible fitting and service, but are we also driving up prices and will we find a backlash as well? Others may say no, it costs too much for the provider’s office to go through the paperwork. By sticking with tight but respectable profit margins, it is better for the business to not deal with the third party payments.
We’ve been discussing pricing issues in our section recently. Hopefully we have given you food for thought on setting prices and dealing with third parties.