Welcome, everybody, to the IHS webinar, Helping Your Clients Navigate Their Medicare Hearing Aid Benefits. I'm your moderator, Alyssa Parity, IHS's Director of Government and Chapter Affairs. Thank you so much for joining us. Before we get started, I want to share a few housekeeping items. Note that we are recording today's webinar so that it can be offered on demand through the IHS website in the future. Also, this webinar is available for one, continuing education credit through the International Hearing Society. The CE quiz and information about how to receive credit can be found on our website, IHSinfo.org. Click on the webinar banner on the homepage or choose webinars from the navigation menu. Lastly, tomorrow, you will receive an email with a brief survey about this webinar. Your feedback is incredibly helpful as we continue to create valuable content for you moving forward. Now, on to our presenter. There is much confusion about Medicare hearing aid benefits, if your clients even have it at all. Samantha Sikorski, ACA, is here to shed light on how to effectively navigate and counsel your clients in understanding their options. Samantha is the owner of Sikorski Hearing Aid Center in northern Wisconsin. She got her start in the industry in 2001, working with hearing loss prevention. She transitioned to hearing loss treatment and earned her ACA designation in 2006. Samantha then worked at Miracle-Ear for five years before joining AccuQuest in 2008. In 2014, she opened her first of two practices. Samantha also serves as the treasurer for the Wisconsin Alliance of Hearing Professionals and is the chairperson of the IHS Managed Care and Compliance Committee. As you can see here, Samantha has much to cover today. In the end, we'll move on to a Q&A session. On your bottom menu, you'll see icons for chat and Q&A. Try to keep general conversation in the chat box, and all questions, which you can send in at any time, in the Q&A box. And now, let's get to our main presentation. Take it away, Samantha. All right, thank you, Alyssa, and thank you, IHS, for creating a venue to get this information out to your members. There really is a lot we can need to cover, but first, we can't really help your patients if you don't understand a little bit of the history, which will then help you to understand why there is so much confusion with Medicare coverage. Hopefully, all of you are familiar with the language or statute that excludes hearing aids from Medicare coverage. When we refer to this statute, we're actually referring to those who carry this card. But it goes far beyond this card, and you know that. But that's because Medicare beneficiaries are able to make choices in their coverage and care options, and they have been for a number of years. One thing I hear every single time I present is that a dispenser actually believes he or she cannot bill a Medicare patient. First, if your patient has Medicare, they're called beneficiaries. I will use that term most of this presentation, so I want to make sure we're clear on that definition. As long as you are operating within the scope of your practice and you're allowed through your state license to perform that service, you can help and bill a beneficiary. Have you ever had a patient tell you they're on Social Security? Social Security is not Medicare. These are two separate entities that have responsibilities that overlap. If you ask your patient what insurance they have and they respond with either Social Security or Medicare, you need to ask clarifying questions. When one turns 65, they are entitled to enroll in the Medicare program. This is known as Original Medicare. A person is eligible for Parts A and B. They actually need to choose or elect if they want additional coverage. Part D is the addition of prescription coverage. They could actually choose a replacement plan, previously known as Part C, or they can choose a Medigap plan, which supplements Parts A and B. They cannot have all of these plans. If the beneficiary chooses a supplement plan, they still have Parts A and B, but can't legally purchase Part D or an Advantage plan, and this is important and you'll see why shortly. But first, let's just take a look at these supplement plans. What is supplemental insurance? Well, supplemental insurance is not exclusive to Medicare. As with any supplemental plan, it takes care of remaining balances. When a beneficiary has a supplemental plan, it covers remaining balances on items that are allowed, keyword, allowed by Medicare, after they've paid their portion. Now that's in stark contrast to the commercial world of insurance, where one could have a supplement plan that covers items that the primary insurance does not allow or cover. The idea with all supplemental plans is that it leaves a little bit of out-of-pocket expense left for the patient. There was a time that prescription drugs were allowed to be covered or included in supplement plans, but that's no longer allowed. Supplement plans are also not allowed to offer discretionary coverage on items that are statutorily excluded, like dental hearing vision. And also please note, when speaking in terms of coverage, I mean a benefit, not a discount. General carriers like AARP will often contract with a discount plan, which allows the beneficiary to call and sign up for the discount plan. If you weren't already aware, anyone at any age can already do this. It's not exclusive to Medicare beneficiaries. Let's look at what happens when an advantage plan is selected. As you can see on this slide, when a member chooses an advantage plan, no other option is available, and that's often while you'll hear people call it a replacement plan. It's also often referred to as Part C. It replaces Parts A and B. These plans are allowed to offer drug coverage, and they are required to utilize rebates to assist with additional benefits, such as dental hearing and vision. The beneficiary still pays Medicare for their insurance, and then Medicare turns and pays the advantage plan carrier each month per member something called a rebate, and that helps offset the cost of coverage. Over the last two, three years, I've been asked by a large, overwhelming number of people to help them understand the new Medicare Advantage plans. As you can see by this slide, Advantage plans have been around since 1997. The biggest change was 18 years ago when the name was changed from Part C to Medicare Advantage, so it really makes me wonder why, lately especially, I'm getting so many calls regarding the new changes in Medicare. Well, that's because in the last couple of years, Medicare did expand coverage. There were some expansions to coverage in 2020, but look, it has nothing to do with hearing health. I mean, service dog support was covered, but not hearing. In 2019, there were some expanded benefits, but again, nothing in the realm of hearing healthcare. In fact, the 2019 and 2020 expansions are referring to benefits that were covered under what was called the traditional primarily health-related benefits, and that started in 2018 and earlier. This means that hearing aid coverage has been around for over three years, right? Yet providers and patients alike seem to believe that there's something new being covered, especially hearing aids. In fact, when I explain to providers that there's nothing new in the realm of hearing aids with Medicare, they don't believe me, or oftentimes they feel that it must have changed only in their state. Yes, this set has something to do with it. Attention anyone on Medicare, 2020 Medicare Advantage plans are now available. Did you know you may now be eligible for additional Medicare approved benefits, including dental, vision, hearing, and prescription drug coverage? The toll free Medicare benefits and questions line is now open. To help anyone on Medicare, make sure you are getting the benefits you deserve. Just call 800-498-9939 now to find out if you're eligible for a Medicare Advantage plan that includes additional benefits like free hearing aids, free eyeglasses, free meal delivery, and free rides to medical appointments. You may also be eligible for $0 monthly premiums, $0 deductibles, or no copays. Just call the. Have you seen that commercial or one even similar to it? Perhaps your patients have come in asking about it. These people and by these people, I mean those advertisers, they know what they're doing. Was that commercial illegal? No. Unethical or perhaps a bit misleading? Well that depends on your personal views. Of course, if you know me, I have mine. But please remember that people hear what they want to hear. Free hearing aids. Who doesn't love the sound of that? But what they say just before that is that you may qualify for things like free hearing aids. We'll come back around how this happens in a bit, but first let's talk about the business of Medicare Advantage, and it is a big business. Now the following slides have charts and statistics that come from the Henry Kaiser Family Foundation. This organization publishes the most robust healthcare information and highlights some of the reasons we're all facing our current challenges. Just take a look at these enrollment numbers. You can see here in the early 2000s, Medicare Advantage enrollment was relatively small and it's been an upward trend since. 39% of enrollees last year chose an Advantage plan. Now if you remember a few slides ago, I told you Medicare, the beneficiary pays Medicare every month, but Medicare turns around and pays those carriers offering these plans per member per month. That's a lot of money in the carrier's pocket. Now that 39% we just looked at was new enrollees. 57% of current Medicare beneficiaries are not even looking at their coverage to determine new options. Maybe I'll make this a little bit easier to digest. If there were 1,000 people living in a small nearby town and 100% of them had at least some degree of hearing impairment, would you mark it to them? Heck, personally, I'd hang a shingle in that town. What this graphic is telling us is that over half of the people on Medicare are not even looking at their current plans, which means they're not electing what could be additional coverage and options, and these big private insurance companies want in on that market. Find your state. If you happen to live or practice in a state colored red or that darker blue, it's likely why you're sitting on this webinar. Medicare Advantage plans have made their way into your daily lives. These patients in these states expect to have coverage, a benefit. They do not expect to be told they only have access to discounts. Conversely, if you're in a state colored orange, you may not be dealing with Advantage plans as much as you are with the supplemental or even discount plans. This is our new normal, and it's about to get tougher. As I said, this is big business. UnitedHealthcare enrolled 500,000 new members, half a million people, and Humana wasn't very far behind. UHC's annual report for 2020 showed 5.7 million of their members were on Advantage plans. That is a lot of money, but not enough to them, and they want more. Now what this slide is showing us is that 72% of new Advantage enrollees have an extra benefit that includes hearing aids or hearing health care coverage. In case I haven't made it clear, in order to offer an Advantage plan, the private insurance must include at least one extra benefit to their beneficiary members. To offer these benefits, the carrier uses rebates from Medicare, as well as charging additional premiums to make up for the added cost of offering that benefit. Now the issue with this particular slide or analysis shown here is that they're not separating access to discounts from real true benefits. In reality, they don't care. It's about the perception of what they're offering. So back to that commercial and the legalities of what they just advertised. How does one obtain free hearing aids? Is that even possible? Well, it is. It happens when the beneficiary chooses a plan where the insurance carrier offers both a benefit and access to a discount plan. The cost of the hearing aids is low enough that the entire benefit covers the discounted product. So a benefit is when monies are paid to insurance, and that money is used to pay on claims. That's a benefit. When a carrier contracts with a third party to extend a discount to a member, that's just access. Supplement plans are allowed to give access, but not allowed to give a benefit. Advantage plans, by the makeup of what they are, are actually required to use rebates to give a benefit. But oftentimes they're giving access instead. Why? Because it's more money in their pocket. In case you haven't done the math already and don't see why or what this has to do with hearing aid access in your business, let's put it this way. People expect their insurance to cover their medical expenses. Those who bear the risk of paying for health coverage want profits, and they'll save money where they can. If Medicare were to pay only $1, it's a lot more than that, per beneficiary every month, that means UHC alone is receiving $5.7 million every month just for the beneficiaries on their advantage plans. Now, if all they need to do is give access to discounts, then they stand to profit in numbers I personally can't even begin to fathom. So let's get to it. Does Medicare cover hearing aids? The reality is this question can't be answered with a simple yes or no. With a supplement plan, it's easy, no. However, with an advantage plan, you must review the policy. So then how do you determine coverage? Well, a card tells you. It tells you if it's a supplemental or an advantage plan. Supplement, no benefit. However, people seem to have this need to call on every plan just to be sure, like maybe they're not confident enough. And what I've seen by going in and helping other practices is that staff members call on these plans and then, horrifyingly, they tell a new prospective patient, well, your insurance doesn't cover hearing aids, but you have access through a discount plan available. You just need to call this number. When the practice doesn't work with that plan, you're sending people away. When I ask why they do this, many, or if not all of them, tell me that they thought they were required to. This is not only false, it's not your responsibility to disclose this to the patient. If you don't feel good about not telling them, then I personally would suggest you don't make the calls. On a side note, it's not the responsibility of the practice to determine what benefits, discounts, or other access is available to their patients. It is the responsibility of the patient to know prior to scheduling the appointment. When a practice calls to determine benefit eligibility, it's a service being offered or extended to that patient. Will this patient have benefits? I hope I've done a well enough job helping you see that this is a supplement plan and they cannot offer a hearing aid benefit, but your patient's going to believe they do. Why? Because they advertise it. I mean, it does technically state that it's a discount program, but how many seniors coming into your office are savvy enough to even know what the heck that means? How many will understand that they have to call someone else to sign up to receive the discounts? Just read the disclaimer, fitness, vision, hearing, and wellness programs are not part of the insurance policy. They're offered at no additional charge and can be changed or discontinued at any time. They're clearly advertising on their website that the coverage is accessed through a discount plan. What they're not saying is who the discount is through or what the value of the discount is. So when your patient walks in, they believe they were automatically enrolled in the plan. But remember, a supplement plan cannot legally do that, and they don't do it. Advantage plans are far more complicated, but the cards offer more clues. However, it does take a person skilled and dedicated to insurance eligibility to understand and figure them out. An HMO is where you need to see a provider within your network. POSs allow more flexibility when added to an HMO. A primary care provider in this instance may refer the patient to a specialist outside of the network. The patient will be able to see the provider of their choice, but will have higher out-of-pocket cost sharing. Here's how this particular plan works in my state. Marshfield Clinic, a very large healthcare system in Wisconsin, owns this insurance company. They're the preferred network. If a patient goes to them, they'll have little to no out-of-pocket expense for hearing aids. Now the member may choose a provider outside of the clinic, but they're required to go through true hearing, and then they'll receive access to a discount, and they will pay hundreds to thousands of dollars more out of their pocket. In other words, the POS point of service designates that the policy payout will be dependent on where the service took place. POS is not code for true hearing. It just indicates to the provider that if you aren't in network with the carrier, then what was a benefit may change to access through discount. Make sense, or clear as mud? Medica is also popular in the Midwest, and it's another advantage plan. However, this card doesn't tell us if it's an HMO, a PPO, etc., and that is our first clue. Instead, it tells us very specifically the type of coverage. One can simply type that information into Google and receive all the policy details. That's because in order for a big insurance carrier to participate in Medicare, private health plans must disclose their coverage details to beneficiaries so they can determine which coverage is best suited for them. Now, this plan is an actual benefit, even though it's a small $400 and in the form of a reimbursement. Let's talk TPAs, and let's face it, this is one thing that I talk about that gets eyes rolling and throats a-groaning like nothing else I discuss. I'm not here to advocate for them, nor am I here to bash them. There are three facts I want to share. One, personally, I don't participate in any TPAs. But two, TPAs have kept some of my friends and acquaintances afloat through COVID. And three, the term TPA is often misused and misunderstood. In fact, recently, I called an organization to ask if they had switched over to a TPA because they were advertising it, and I knew them to be a discount plan. The man I spoke with on the phone said, yeah, we're a TPA. So I was like, oh, I didn't know you started administering the plan and processing claims. And then he was confused and said, no, what we do here is contract with insurance carriers to get their members discounts. Do you see what I mean? People don't know what TPAs actually do. Are all of these people TPAs? No. A third-party administrator is an organization that may underwrite a policy, it may process a claim, or it could administer the benefit plan. Now, in some cases, these organizations do operate as a third-party administrator. However, in other cases, these organizations only operate as a discount plan. In order for you to make a decision on whether your practice should network with such an organization, you should know which one you're dealing with. In many cases, it's easier to offer your own discount to compete with business when they only have access through a discount plan. Conversely, when dealing with a TPA, these organizations have better purchasing power and they can buy hearing aids far cheaper, making it nearly impossible to reduce your pricing enough to compete. Another reason one should know which type of organization they're dealing with is in terms of how long it takes to receive reimbursement. Do you get paid directly from the patient? Or does the patient pay a middle man leaving you to wait 45 to 60 days for payment on your work? Your decision to participate in a discount plan is yours alone, but let's face it, this is how Medicare beneficiaries are obtaining hearing aid coverage. I want to highlight a few things everyone should be considering before determining if it's best for your practice. I realize not all of you on this webinar own your practice or have the authority to make these decisions. Let's just review a couple often overlooked aspects of participating with them. If the company's original or initial break-even analysis and business plan were based on private pay sales, one may quickly find themselves working harder for less profit. You may want to consider writing out the fitting fees being offered by the TPA to determine if the break-even for these types of patients makes sense. And before deciding against all TPAs and discount plans, one should consider the effect of non-participation. Recently, a long-time patient walked into my office and requested to see me regarding some issues he was having. I happened to walk out of an appointment and saw he was holding a remote. The hearing aids I fit him with didn't come with a remote. Confused, I walked up to learn about the issues and noticed he was wearing different hearing aids. He explained that he received a letter from his insurance company and he could, for $500, get the newest technology hearing aids. His were four years old. He then explained that he couldn't hear with them, but since he paid for them, he wanted to know what I could do for him. I did suggest he let the audiologist that he went to know he was having issues, and he said, I only went there to get the hearing aids, but I figured you could take care of adjusting them. As a non-participating provider, I really have to be okay losing people to competitors to get hearing aids covered by their plan. If I wasn't okay with that, then I'd need to join the network and accept their contract rates and rules. When a patient purchases hearing aids through their network provider, the focus is often on the price of the product. It's rare that one gets into discussing what services come with it and the cost of continued care. TPAs don't require lifetime services, so the patient is going to pay additional funds out of their pocket. So, instead of focusing on the product, one could focus on the follow-up. Let's take a look at another recent case. Three weeks ago, a patient came to me because she lost her right hearing aid. It was a little over five years old. We're now faced with three options. Well, four. She could do nothing, but she could replace it with a brand-new set, which would set her back $3,500 or more. She could replace just one hearing aid for $1,500 or so, or I could send her to an in-network provider where she could get a new set for $500. Am I crazy for suggesting that? I've been called worse. This is how it works. Back up. It's not my intention to indicate how any person should operate their business. This next slide is meant to illustrate how Sikorsky Hearing deals with patients who purchase elsewhere or through their network, but they desire services to someone who specializes in the function and care of their hearing needs. For various reasons, I prefer to do my own testing. However, most physicians will order a test citing medical need for the patient so that it's covered by Medicare. When that happens, they have to see an audiologist. When the audiologist does the test, they forward it to me. I explain the results to the beneficiary, and I also state why speech and noise, MCL, UCL, and binaural word recognition testing are necessary, because when seen for medical needs, those tests aren't done. And I bill the beneficiary for my time in those tests. Insurance is not going to pay for them, but it doesn't mean I shouldn't follow best practices and charge for them. Of course, I'm not getting the fitting fees from the TPAs. Yes, the competitor got paid, but the patient doesn't know or understand how this works. Furthermore, I'm not going to suggest a prospective patient go back to the provider for all their care if they want the care through me. Meanwhile, I take care of their needs. I'll run conformity evaluations like real ear measurement or the hearing instrument test box. I'll check the devices and program them accordingly. Of course, they all need follow-up care. You could offer a prepaid service plan, sometimes called an adoption fee, or do a fee-for-service option. And even though I am not billing insurance, I bill using the appropriate codes. In other words, it doesn't matter to me what their insurance covers or denies. As a person who doesn't participate in TPAs or discount plans, I just bill for my time. Let's look at fee-for-service from the patient perspective. Impaired Ermie needs to decide if she wants someone in her network or someone else. Obviously, programs vary in their fitting fees offered to the provider, but in a typical TPA, we see reimbursement rates for around $500 to $700, but require a specific set of follow-ups to be included in that fee. As a non-participating provider, you lose the opportunity to receive payment for a dispensing fee. However, you may charge the patient your usual customary and reasonable pricing for each service used by itemizing those services. Now, from a patient perspective, they pay the provider a set amount for the product. They have an option to pay a different provider for their follow-up care. Even when this happens, they still save a significant amount of money, and the non-participating provider, me, still receives more money than they typically would participating in the TPA. So, let's summarize this. Medicare does not cover hearing aids, and it only covers tests when done for the purpose of a possible underlying medical condition. Medicare supplement, or those Medigap plans, offer no benefit. A beneficiary on a supplement plan could obtain access to a discount, but it's not through Medicare. And Medicare Advantage almost always has access to a discount, 72% we learned, right? They may also have a benefit. If you participate in several different discount plans, you need to take a closer look at the supplement plans. If you don't participate, you don't need to call on those plan cards. Let's look at it another way. Frugal Fred decides he doesn't want anything beyond what he's entitled to receive from Medicare, but he is taking a lot to receive from Medicare, but he is taking a lot of prescriptions, so he adds Part D to his plan. At the next enrollment period, he decides he's tired of receiving so many bills for copays and coinsurances that he changes to a supplement plan. When he does this, he loses his prescription coverage. Now, his wife, Vane Velma, wears contacts, she takes very good care of herself, and she doesn't want to be limited by Medicare's policy, so she opts for an Advantage plan. Because this replaces Medicare, she will be participating in a private insurance plan, even though her monthly premiums are paid directly to Medicare. She now has access to various extra benefits, but she may not realize the differences in her options when purchasing the specific policy. So, how do you know if the plan offers coverage or access? Q1Medicare.com is one site that allows you to search policies. Look at this plan in Arizona. It tells us that limits apply. When you see limits apply, it really means that they are through a discount plan most always, but they use that word when it's through a reimbursement as well. What it means is there's something available, but there's a caveat to obtaining that coverage. Conversely, this plan, this Medica plan in Wisconsin, clearly tells us they are not covered. And a side note, if you see on here, the hearing exam is covered. That doesn't mean a person can go anywhere. It often means that they need a referral from their primary care provider and an audiologist has to do it because they're not looking at the test for purposes of fitting or dispensing hearing aids. It's for the patient's or beneficiary's overall health. Medicare.gov slash plan hyphen compare. Now, that's similar to Q1Medicare, but it's far more user-friendly. It tells you how many plans are available in your county. So, Medicare's federal program, it's not varying by state. It varies by county, and I love seeing this. Be aware, however, that this site gives a check mark when the plan has benefits for hearing, but oftentimes that benefit is only for a hearing exam. My point is illustrated here. It says that hearing is a benefit, right? But it clearly only offers coverage for a hearing exam. Also notice that the coverage is 20%. But it doesn't tell us what the allowed amount is. So, whenever you see a percentage, you should always ask yourself, of what? 20% of what? But again, if it shows a hearing exam is covered and nothing with hearing aids are recovered, that's likely when you'll see that it has to be done by an audiologist for the purpose of medical needs, medical care. Please use caution when you use these resources. They require you to input a zip code. Make sure you use the zip code for your patient. There are two counties in Wisconsin that have 47 different plan types. My county has 17, and the county just northeast of me only has 11. If you input the wrong zip code, you may find the same plan name, but you could actually have a different policy. When speaking with a patient regarding their coverage, one should tread very lightly. Have you ever had a patient ask you which plan offers the best hearing aid coverage? My patients don't know that I even know anything about insurance, yet many of them come in prior to signing up for Medicare and say, hey, which plan is more favorable to hearing aid coverage? They just want my opinion. The best advice I can give you is to refer your patients to a benefits specialist. Help them understand the difference between benefits and discount plans. So back to that Medica plan in Wisconsin. Medica, or it's actually in the Midwest, but they offer four different plan types. Only one of those plans does not cover hearing aids. Three do. So what if a patient came in to me and said, Samantha, which is the most favorable? And I said, oh, it's Medica because it's a $400 reimbursement, and at least it's a benefit instead of access to discount. But I don't say all that, and I just say it's Medica. And then they go ahead and sign up for Medica, but choose the one plan that doesn't offer access to the benefit. What would you suppose they do when they showed up for new hearing aids? Just don't do it. It's a risk. If you're a benefits specialist or you employ a benefits specialist, you may decide to take that risk on and employ someone to talk to them, but as a provider or front staff who's scheduling patients, I strongly recommend you don't do it. It's not worth it. All right. So Q&A time. I hope that I left you with some information that cleared some of the confusion up, and we'll have time if I left you totally, thoroughly confused. Thank you, Samantha. Let's take some questions. As a reminder to our attendees, if you have a question for Samantha, enter it into that Q&A box at the bottom of your screen. We'll take as many as we can in the time remaining. Our first question is from Ebony. Okay. Listen up. There's some details here, Samantha. Okay. I have a patient with an Anthem Blue Cross Medicare Advantage plan through LAUSD retiree. The plan has no deductible and no out-of-pocket, no copay, and the plan itself covers two hearing aids every 36 months, covered at 100% on $2,000 per year. You might know where I'm going with this. They also have an option of HCS. My question is if they choose to get their hearing aids through the plan at the $2,000 max per year, are we allowed to bill them for any amounts over the $2,000 each hearing aid? I love this question. Okay. I'm a nerd. This is a really fantastic question. It depends if you're in-network. So let's back up and say, because she didn't clarify, but let's just say I'm in-network with Blue Cross Blue Shield, and they're allowing $2,000 per hearing aid. That's the max they're going to pay. I decide to fit this person with $5,000 hearing aids. It, as a pair, $2,500 each, it means that I am obligated per my contract to write off the additional $1,000. The patient cannot be billed. If I am out-of-network with the plan, so it covers me as an out-of-network provider, I would receive the money from the plan allowance, $2,000 per hearing aid, and I would be able to bill the patient that $1,000 remaining balance. It was up to the patient to come to me as an out-of-network provider knowing that they're going to be on the hook for that overage. The third option that patient had was to use a provider that was in network with hearing care solutions because this is an advantage plan that I talked about that offers both access and a benefit. If I was a provider not in network with Blue Cross but in network with hearing care solutions, I would be able to get the hearing aids to the patient for a discount and then 100% of the hearing aids would be covered through her plan. I hope that answered the question. If not, ask a clarifying question. Okay, our next question is from Steve and I love this one. Is this all covered in your managed care manual from 2019? Well, that's why you love it. I was going to say Alyssa's becoming a nerd. Okay, the reality is this is an ever-changing landscape and we're learning a lot more here. So, not all of this is covered in the previous. It's just the way it is but as members of IHS, you all have access to a lot more robust information coming down the pipe. So, I'd say stay tuned. I think we can safely say that we're working on the next edition and it's going to be incredibly robust and speak to these types of issues. So, as Samantha said, stay tuned. Hopefully that'll be coming out this year as the plan. Okay, let's see. We've got a question from Helena. All language is stating audiologists. How does this apply to hearing aid specialists? When a plan, especially many Medicare plans, they write in there that they need to be seen by an audiologist. When that occurs in my practice, we call and clarify with the actual taxonomy code for a hearing instrument specialist. And in quite a few of them, they say, yes, that taxonomy is covered. For some reason, you have to understand maybe, maybe you don't have to, that was a strong word, but you should understand that they just use audiology as almost a global term. So, if they say audiologists are covered, they may mean that anyone who is licensed in the state to perform within their scope of practice. However, in some cases, they really mean an audiologist and that is because the service is only covered when performed by a person who could do diagnostic testing. And we know that a hearing instrument specialist cannot do a hearing test for the purpose of diagnosing any ear disease. All right. Next question is from Sue. Can you explain how folks with the TPA like True Hearing are allowed to get new hearing aids every year? Well, that's a challenging question because I would say maybe I don't understand it. An insurance carrier, especially one who administers the plan, can decide how often they want to dispense hearing aids. So, if I were creating a benefit plan, I could say, I'm only going to offer them every three years. You may know that the Federal Blue Cross has now moved from a three-year to a five-year. How often are they willing to cover it? If there's a TPA that wants to cover it every one year, that's their prerogative. But maybe I misunderstood the actual question in case there was something deeper in there. All right. Let's move on to the next one. This is a question from Melody. Is the ability for a dispenser to bill CPT codes determined by individual state statute? I thought as a dispenser, I can only bill pickpicks and not diagnostics. You're not diagnosing? This is a really good question. So, I need to step out of our profession for a moment and explain what I learned working in an actual clinic. A patient calls in and says, I'm having leg pain in my right leg. And they go see the doctor and the physician says, diagnoses them with something that's going on in the foot. The diagnosis code for the appointment is actually a diagnosis code, an ICD-10 code for leg pain, because that's why they presented. So, it's the chief complaint, what that person was doing in your office. And that's similar to what we're doing when we bill insurance. What we're saying is, why did this person present to the office? Bilateral hearing loss. They have complaints of bilateral hearing loss. That's why they're here. We're not diagnosing them. We're just saying that's why they presented to our office. And you have to have something to warrant a treatment option of hearing aids when covered by insurance. That's how the world works. So, what I would do in your notes, whether you chart them with the audiogram, you SOAP note, however you write them, when you do your assessment, I would strongly encourage you to use the verbiage, hearing loss is consistent with X, Y, and Z. That way, they clearly understand you're not diagnosing them with sensorineural bilateral hearing loss. All right. Thank you. Okay. We have a question from Joel. How have you determined what your customary rates are for each of your services? That's coming out in the update. Okay. So, what I've done personally is I have to figure out, just like any breakeven analysis, what are my fixed costs? What do I have to make every hour I'm open to pay my bills, pay my staff, utilities, and all that fun stuff? And like everyone else, I'm not here as charity. I need to make a profit. So, first, I figure out what my breakeven is and then what I need to make as a profit. And it tells me right then what I have to bill per hour. I will write down all the services I offer. So, if I do a cleaning and it takes me 15 minutes, I know by per hour, I divide that by a quarter and my UCR is that rate. Whether that appointment took me 10 minutes or 20 minutes, I bill at a 15-minute fee. Great. You just took something really complicated and made it pretty simple. Okay. Question for Mohamed. How come a non-participating provider can receive more than a participating provider? Well, that's the benefit of signing those contracts. You know, when you get presented with a contract, read it carefully. There is some language in there that you may not really like and you have to know in the contract what you're giving up. So, one contract I received recently spelled out how large my bathroom had to be. It told me that my staff had to have certain vaccines, but it also stated that I had to be available 24 hours a day. That's ridiculous to me, right? So, the compromise there is you offer this to our members and we will get you in network. And the benefit to me being in network would be that when they advertise or when a patient calls or a member calls and says, who's my network provider? They're going to say my name. So, why would I receive more than a competitor? Because insurance is paying a hundred percent of it. Whereas if I'm out of network, insurance is paying based on their allowable, they're sharing cost with the patient, and then the patient in states where you're allowed to balance bill, because there are some states where you're not, but in those states where you're allowed to balance bill, then the remaining balance is to the patient or member. Managed care, a tidbit of history, if you're a nerd, managed care came out to do a few necessary things. And one of them was to control the health care costs. They were skyrocketing 30 years ago. So, it needed to control cost. This is insurance way of controlling the cost. Just because an in-network provider makes more money, it doesn't mean insurance is paying more because there's cost-sharing factors that need to be considered. So, insurance pays 80% to the in-network provider up to their allowable. Most times they're getting screwed bluntly. There's an offset there that you have to consider. All right. We have a question from Tom. Is there any movement, and there's kind of a two-parter here, is there any movement to one, get hearing instrument specialists added to be able to do Medicare-covered testing? And two, is there any effort to change laws to force the insurance companies to be more forthcoming as to what the real benefits are? I see many patients who are purchasing these coverage plans specifically due to advertising stating free hearing aids. Let's talk about the first question in there. Is there any movement to get hearing instrument specialists allowed to offer this? I will say it this way. I specialize, I am educated, and I am good at hearing aids. And that's what I tell my patient. I'm really good at hearing aids, but I'm not a diagnostician. I don't have the education that gives me that skill set. I don't know vestibular system like an audiologist does, because I didn't go to school for six years to get that education. But I'm really doggone good at the hearing aids. And so, while one could have a valid argument that we should be able to be covered for hearing tests, we have to understand the purpose or intent of offering those tests. They only want to pay for tests if it's based on a medical need, not on hearing aids. So, we first have to work at Medicare to cover hearing aids, right? Once they cover hearing aids, then the hearing instrument specialist by nature would be able to offer the services. But that's a long, long battle ahead of us. The second question. The second part of that question, can you recap that for me, Alyssa? Yes. Is there any effort to change the laws to make insurance companies more transparent in terms of the benefits? There are. So, Alyssa and I happened to, now, gosh, we're almost two years ago, went to a very large convention that was directed towards health insurance providers. And they want this transparency. The reality is, I would say that they are being somewhat transparent. I take it on myself to educate everyone I see the difference of an access versus benefit discount and such. And so, we as a community could band together to make sure we're educating the public. I talked about security health plan. The clinic owns it. I lose people to them all the times to buy their hearing aids, but I'm actually making more money because they're coming here for follow-up care. Now, what I'm trying to do, I went to security health plan myself and argued this. They have their reasons for offering it this way, but what I've decided to do here is talk to the people buying the plan and say, you know, maybe security health plan isn't the best plan for you. Here's why. Here's how. But we have to understand as professionals, hearing aids aren't the only thing the beneficiaries are looking at. My dad was just put on a prescription that cost $900 a month. That's a lot of money. And so, they're grappling, my parents are grappling at figuring out which Medicare plan is going to help them bring that cost down. Hearing aids aren't even in their question. And it's not because I'm a hearing aid provider and they can get them, but vision dental hearing has now taken a back seat to what the cost is for their whole health benefit plan. All right. We've got a couple more great questions that hopefully we can get through. Okay. This is from an anonymous attendee. I'm in a few TPAs. If I get a patient calling about a benefit in their plan and I'm not in it, in order to retain the patient, I often offer them another network. Is that okay to do? There's nothing, that's your choice. 100% great question. There's nothing legally that says you can't refer them to something that can help them get discounts and put you through that. That's a great question. No, there's no law that says that you can't give someone access. All right. Here's a question from another anonymous attendee. Do you make it clear to your patients that you do not check if they get discounts or what the discounts may be, or do you just say nothing at all or act like they don't have options for discounts through their insurance? If you see where we're going with this, we may not be obligated to report discount options the patient may have when we check for benefits and our services may outweigh any discounts the patient may be able to receive through a discount program, but is it ethical not to disclose this and let the patient decide? Okay, good question. I often tell my young son, it's okay to agree to disagree, and I also learned that you can't put your ethics on someone else, right? So while you may feel ethically obligated to tell people, that's kudos to you and that's your choice. I, a year ago, had a cancer scare and I needed to breast MRI imaging. I was referred to a place that was in my network to get the breast MRI, and I got a bill that was just shy of six thousand dollars, and I was ticked. That's a lot of money that I didn't expect when I called and I checked everything, and it so happens that the person, the physician, reading the MRI was not in network because the guy that I was scheduled with was out of the office that day. The insurance, when I called and argued him, said, well, it is your responsibility to know that and check it ahead of time, but we'll try to negotiate them, and that's why sometimes you guys will receive faxes from repricers. They try to negotiate without a network providers. What I will say is this. I personally, when I call and learn they're on a discount plan, if it's a discount plan where I know that I can compete and be cheaper, I just personally don't feel like I need to have that conversation because it's going to add more confusion to the appointment, but as I said earlier, two patients, one patient I sent up the hill to a competitor to get hearing aids because it saved them money and then put her on a plan where she paid me the thousand dollars for fitting follow-up care, so I'm not anti-saving the person money. I'm just saying it isn't our responsibility, and sometimes we get into their personal lives a little bit more than a physician at any other clinic would. All right. I'm going to try to squeeze in at least one more question here. A question from Terrence. What avenue is best to follow when one of our patients is billed additional out-of-pocket expense even when their provider accepted contracted reimbursement from their TPA? Okay. If you ever accept a contract that we're talking about, this is the allowable, you accept the rate, you are in network, no matter if you are in a state that allows balance billing or not, you cannot bill the patient a remaining balance. That has gotten some people into a lot of legal trouble, so it also has been the reason why most insurance companies are going to someone else to administer their plan because of those misconceptions that you could bill above the collected or reimbursed amounts, so use extreme caution and know what your contract is. If an administrator tells you this is the plan amount and it pays you that amount, you can't accept anything more than that. And be careful, too. Some of them say upgrades are allowed. If upgrades are allowed, get permission, then the patient could pay the balance if you're in a favorable state. I'm going to squeeze in the very last question that we have here, if you don't mind, Samantha. Yeah. This is from Peter. How does the any willing provider rule and law fit into this maze? I would say it really doesn't fit into this, right? So that's a very complex one, and we are addressing this a little bit more. Any willing provider really means that I, as a patient, call my insurance and no one around me is offering coverage. The insurance carrier can network with any willing provider in the area to offer a contracted or negotiated rate for their patient. That's really what it means, and it doesn't fit into the Medicare landscape, per se. All right. Well, that is the time that we have today. Thank you for the extra time to answer these questions, Samantha, and for this incredibly valuable presentation, Helping Your Clients Navigate Their Medicare Hearing Aid Benefits, definitely in quotes there. To get in touch with our presenter, you may email her at samantha.sikorskyhearing.com. We know this is such an important topic to you, as is evidenced by your many questions, and there is so much to unpack. I'm pleased to share that IHS will have additional coverage about this in our upcoming The Hearing Professional magazine, IHS's exclusive magazine with industry news, updates, and details for IHS members only. If you don't already receive it, let us know at the email on your screen, and we can share more information about membership with you. As a reminder, for information on receiving a continuing education credit for this webinar, visit the IHS website at ihsinfo.org, click on the webinar banner or on the webinar tab on the navigation menu. Also, keep an eye out for the feedback survey you'll receive tomorrow via email. We ask that you take a few moments to answer some brief questions about the quality of today's presentation. And lastly, thank you all for joining us today. We will catch you at the next IHS webinar.

webinar

Medicare hearing aid benefits

Medicare coverage

Medicare supplement plans

Medicare Advantage plans

hearing aids

plan details

benefits specialists

third-party administrators

transparency