Managed Care & Compliance (Q1 2019)-Managed Care & Compliance (Q1 2019)

Managed Care & Compliance (Q1 2019) - Article

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The insurance landscape for hearing healthcare practitioners has become increasingly complex with the rise of Medicare Advantage plans, replacement plans, and competitive markets. Insurance carriers are offering perks such as vision, dental, and hearing benefits as part of their health plans or through third party administrators (TPAs). However, understanding insurance jargon, terms, and policy coverage can be difficult even for those educated in the field. To address this issue, the International Hearing Society (IHS) has established the Managed Care and Compliance Committee to provide educational resources and guidance on insurance billing rules, legal ramifications, and correct coding for reimbursement. The committee aims to assist IHS members in gaining a deeper understanding of insurance practices and boosting confidence in billing procedures.<br /><br />The article also discusses the challenges of maintaining compliance and the need for hearing healthcare practitioners to navigate insurance protocols and prove medical necessity for recommended treatments. Insurance companies often have their own fee schedules, terms, and policy groups, making it difficult for healthcare providers to have a clear understanding of what is covered by a patient's policy. The article emphasizes the importance of understanding insurance contracts, verifying benefits, and properly coding claims to ensure appropriate reimbursement. It also highlights the need to bill at usual, customary, and reasonable rates to maintain compliance and avoid insurance fraud.<br /><br />Additionally, the article mentions the rise of third party administrators (TPAs) and their impact on insurance reimbursement. Insurance carriers often analyze billed charges and modify their fee schedules based on the analysis, which can affect reimbursement rates. The article warns against the practice of bundling and billing at higher rates, as it may not lead to increased reimbursement and can attract third-party discount plans that aim to reduce reimbursement costs.<br /><br />Overall, the article highlights the importance of understanding insurance practices, following coding and billing rules, and staying informed about changes in the insurance landscape to ensure proper reimbursement and compliance.

Keywords

insurance landscape

hearing healthcare practitioners

Medicare Advantage plans

replacement plans

competitive markets

third party administrators

insurance jargon

policy coverage

reimbursement

compliance