Audiology Insurance Verification to Avoid Reimbursement Pitfalls

by | Published on Jul 9, 2018 | Insurance Verification and Authorizations

Audiology Insurance Verification
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Audiologists provide comprehensive hearing tests including vestibular tests, hearing aid services such as hearing aid evaluations, fittings, repairs and adjustments, sale of hearing aids, hearing aid fitting, and hearing aid counseling and aural rehabilitation. Outpatient audiology services are usually covered by health plans, but with limitations, making audiology insurance verification crucial for efficient medical billing. In fact, as a report in The Hearing Journal notes, for many audiology practices, coping with private insurance and other third-party payers has long been “more of a hassle than it’s worth”. Today, audiologists, physicians, non-physician practitioners (NPPs), and hospitals are realizing the benefits of partnering with audiology insurance verification companies to manage the patient eligibility verification and preauthorization process.

Audiology Services – Coverage, Limitations and Exclusions

According to the American Speech-Language-Hearing Association, 20 states require that their health benefits plans cover hearing aids for children, and in three of these states, health insurance plans are required to provide hearing aid coverage for adults. Understanding coverage, limitations and exclusions is crucial to ensure a smooth medical billing process:

  • Reimbursement for audiology services varies depending on where services are provided and the type of payment coverage that the patient might be eligible for
  • Evaluations to detect hearing loss and services related to degenerative hearing loss may or may not be covered by private insurance.
  • Almost all private health insurance companies cover audiological diagnostic services based on “medical necessity” as documented by the physician for an audiologic evaluation to test for a suspected diagnosis (e.g. hearing loss unspecified, sensorineural hearing loss, conductive hearing loss, etc.).
  • Hearing aids are covered by some plans when the hearing loss results from an illness or injury, but many private insurers exclude hearing aids.
  • Some private health plans may cover only a partial cost of the hearing aid or reimburse the patient for a set amount.
  • Medicaid covers hearing aids and other audiology services but coverage varies from state to state. Based on broad federal guidelines, each state administers its own program, and establishes its own income eligibility standards, type, amount, duration and scope of services covered.
  • Medicare covers certain diagnostic hearing tests and some Medicare Advantage plans include coverage for hearing aids. However, traditional Medicare does not cover routine hearing exams, hearing aids, or exams for fitting hearing aids. There is also no provision in the law for Medicare to pay audiologists for therapeutic services.

These exclusion policies and coverage restrictions pose significant challenges for billing audiology services. Audiologists and hearing instrument specialists need to consider each opportunity carefully before signing a third-party contract and verify patients’ hearing aid benefits prior to discussing device options with them. It is the patient’s responsibility to pay for audiology services that are not covered by the third party payer.

Prior Approval

Payers require providers to obtain prior approval before the provision of certain hearing and audiology services. If claims are submitted for such services without obtaining approval, these services will not be reimbursed as billed. Payers will not give prior approval for an item or service if a less expensive item or service is considered suitable to meet the patient’s need. When prior approval is given, providers should verify the patient’s eligibility on the date of service.

What Audiology Insurance Benefits Verification Involves

Insurance verification is a time consuming process that involves checking each patient’s hearing aid benefits eligibility, responsibility, and plan requirements before the patient comes in. The following patient coverage and benefits should be verified every time services are provided:

  • Patients name and demographic information
  • Policy number
  • Coverage – Primary, secondary, tertiary
  • Coverage for hearing aids, BAHA bone conduction hearing implants, cochlear implants
  • Participating provider / in-network provider
  • Patient policy status and effective date
  • If the patient allowed to share in cost of the device if they chose technology beyond their benefit
  • Out-of-network benefit (if not an in-network provider)
  • If the hearing aid benefit is monaural / binaural or annual
  • Provider discount if any and amount
  • Deductible and when it was met
  • Co-pay and coinsurance
  • Plan requirements (prior authorization, Medicare denial, referral, prescription, etc.)
  • Whether codes to be billed are covered, and if not, how uncovered codes are handled

Having an audiology insurance verification company handle procedures for collecting patient information and verifying insurance eligibility will support a smooth claims and billing process. Insurance verification specialists will have extensive experience in working with government insurance as well as commercial insurance companies. They will communicate with carriers regarding clinical information requested and strive to resolve coverage and payment related issues for specific patients and benefits. Partnering with an experienced service provider can promote streamlined insurance verification and prior authorization that can help reduce denials and drive higher reimbursement.

Read our FAQ on Hearing Aid Insurance Verification.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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