Hello. Welcome, everybody, to today's IHS webinar, the latest on Blue Cross Blue Shield Federal Employee Program Rules. I'm your moderator, Sierra Sharpe, IHS's Director of Professional Development. Thank you so much for joining us today. Before we get started, I just want to share a few housekeeping items with you. Note that we are recording today's webinar so it can be offered on demand through the IHS website in the future. Closed captioning is also available and can be turned on using the Zoom toolbar as shown on the screen. This webinar is available for one continuing education credit through IHS. The CE quiz and information about how to receive credit can be found on the webinar webpage, which is shown on the screen and linked in the chat box. The slides for today's presentation can be downloaded from that same page. Feel free to take a moment now to do so if you'd like to follow along. Following completion of the CE quiz, you'll be asked to take a three-question evaluation. We appreciate your feedback and use it to create future content for our valued IHS members. And now on to our speaker. Here to provide us the latest on the Blue Cross Blue Shield FEP rules is Samantha Sikorsky, ACA, CPCO, CDP. Samantha is a licensed hearing instrument specialist, certified professional compliance officer, and certified dementia practitioner who owns and operates a hearing wellness practice in northern Wisconsin. She specializes in practice administration and managed care participation, as well as implementing best practices for hearing care professionals and patient education. Samantha began her career as an occupational hearing conservationist in 2001. After developing endolymphatic high drops in 2002, she switched gears from hearing loss prevention to hearing loss management options, and in 2002, became licensed by the state of Wisconsin as a hearing instrument specialist. She obtained her audio prestology designation from the American Conference of Audio Prestology in 2006 after completing the 13-month program and 120-hour practicum. Most recently, in 2022, Samantha passed her certification exam offered through the American Academy of Professional Coders and became a certified professional compliance officer. In addition to her hearing center, Samantha owns a compliance practice, Thistle LLC, and co-founded a software company, SmartCare.io. And as you can see, our expert speaker has much to cover today. At 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 your general conversation in the chat box and all your questions, which you can send in at any time, in the Q&A box. I do expect that we'll get a lot of questions for Samantha, so if you can please make sure those are going in the Q&A box, that will help us keep track of them and keep them organized and get through as many as we can with the time that we have. So without further ado, let's go ahead and get to our main presentation. Take it away, Samantha. All right. I'm just going to share my screen here. Well, thank you so much, Sierra. I am so excited we're able to bring you some answers and assistance with the Blue Cross Blue Shield Federal Employee Program. Firstly, I want to congratulate IHS on all its efforts getting in front of this and doing it so quickly. Now, to you on the call, it may not have felt quickly, but believe me, what we accomplished here was a pretty big deal. I would love to just give you answers, a quick rundown, what you need to do and how to get your patients getting their reimbursement, but the reality is you first need to understand how we got here. So let's start there. Now, to understand the depth of the situation, you must first understand the Federal Health Benefits Program and how large this program is. They cover over 9 million federal employees, retirees and former employees and their spouses. To put this in contrast, Amazon has a little over 1.5 million employees and over 2 million FEHB policyholders are retired. There are literally more retired FEHB policyholders than there are Amazon employees. This is a huge number of people who statistically need our services, and even better, we have coverage for them, coverage that used to be super easy to access. In fact, it was almost too easy. I'm the last person you're going to find that's happy they made this decision. If you were here the last month, you'd see how much time I've spent on this, so I don't like that they've made it more difficult for us. But in a few moments, I think you'll come to appreciate Blue Cross Blue Shield's Federal Employee Program's intent when it came to creating this new policy. Perhaps I should explain now that FEHB and FEP are not the same thing. FEHB, it's the overarching, that's the program, and FEP is one of the types of plans offered by Blue Cross Blue Shield. Now on your screen, this gives you a better look of FEHB overall. It's nearly a decade old. It's the latest information I could find, but it helps you see there's a clear preference of carriers by the policyholders. I mean, it's not even close. Now, I want you to step back and imagine that you're the carrier. You are funding over 2 million federal employees and retirees, and you're authorizing nearly $40 billion a year on health care expenses, money that largely comes through federal funds. Personally, I don't remember a single time in my life where the public was not interested in knowing how the federal government is spending their money. Right? Well, the executive director of Blue Cross Blue Shield's FEP program laid this out very clearly when we met with them last week. She said, we must be good stewards of federal dollars. And on principle, I think we can all agree with this statement. And while I'm not going to disclose the name of the company, I want to run through the situation that led to the development of this new policy. I'm sure you'll figure it out, most of you on this call. But for those that don't know, Blue Cross Blue Shield and the federal employee program are registered trademarks. What that means is you cannot use their logo, their likeness, or their name without their permission. And a few years ago, that's exactly what happened with Brand X. They were advertising that federal employees may be eligible for their product with little to no out-of-pocket cost to them. And that skyrocketed their business. Now, it's important to recognize that Blue Cross Blue Shield has always had a policy which only allowed FDA-approved hearing aids. And as you know, this is where things got a little bit tricky. Because the FDA created the new class of hearing aids called OTC. That's obviously not new to anybody on this call. But what really happened with Brand X is something we see happening across the United States. Providers and their practices believe that an issued payment to them by a health plan meant the claim submission or their actions were legal. I see it all the time. I got paid for it. They issue the payment and do the auditing later in a lot of circumstances. Just because you were paid for something does not make your claim legal. Please, IHS's Managed Care and Compliance Committee has created a guide for you. If you do not have that, I encourage you to obtain it, review it, and do your best to follow it. Reach out if you have any questions. Now, every health plan that covers hearing aids will, typically through a utilization management document, tell you what is as well as what is not covered as it relates to all types of health care, including hearing aids and their technology. Now, a sidebar. One Minnesota health plan I work with doesn't cover hearing aids with noise reduction features or Bluetooth. And there are actually several Blue Cross state plans that don't consider CICs a standard hearing aid. That's an upgrade. So you have to be watching these UM guidelines. Everyone has them. Billing a carrier for such can be a false claim. It doesn't mean it always is. Network status, your contracts, those are all very important here. But regardless, this is what got Brand X into such big trouble. What you're seeing on this screen is the outdated version of the FEP guideline. My point in showing you this is to ensure you, A, don't reference it anymore. But it's also to make you aware that this is not a new policy. It's the same thing. They're UM guideline 005. It's just been updated. So this is the October one. There are several iterations since they adapted it. So we need to look at how it was adapted so that we can be ensured that you are compliant. Okay, so let's start with how do you know that you have the most recent policy? Well, as you can see at the top of my screen, that website, keep track of it. FEPblue.org guidelines. As you can see, this is the new one. The effective date is January 1st. This is only the heading of the guideline. And it's really important for us to just know where to find it. But what happens with these guidelines is the Federal Employee Program, the overseeing of this, sends this to the states. The states have independent Blue Cross, right? And unfortunately, due to cautions that stem from the Brand X issue, the states largely overreacted and misinterpreted much of the policy change language. But because of quick actions of IHS, we were able to get the FEP to issue an FAQ, a frequently asked question document, to the Blue Cross states with much needed clarification. That said, I've pulled out the top four issues that have been most problematic. People calling and asking or emailing and asking all these questions with respect to this policy, as well as those that I believe you really need to pay close attention to. By the way, these are in a particular order. These are the Samantha order by importance. First, the 40 decibel pure tone average. This one feels like it hurts most, frankly. And because of that, I plan to continue to work with FEP policy committees on this one. I should warn you that even if I'm successful, we likely won't see changes for several months. It's unfortunate, but it's true. Policy takes time. So let's dive in. Prior authorizations, when submitted, are reviewed largely by non-hearing care professionals. Heck, most of the time it's a registered nurse. They're not trained to review and interpret the actual test results. Therefore, you need to be ensured that you're interpreting the results. You have to provide a clear recommendation based not only on the impairment, but the impact the impairment has on your patient client's quality of life. We look at audiograms like this one, and we can immediately get a sense of this person's daily challenges, right? But we do that because we recall challenges of those who've come in with similar losses. That's experience. And I think everyone on this webinar can agree that this person has impaired hearing. Unfortunately, with the 40 decibel requirement, this person wouldn't be approved for hearing aids. However, within that guideline, there is a consideration clause that directs Blue Cross Blue Shield plans to consider the individual's need for hearing losses of 40 decibels or less with a prescription from a licensed health care provider. We're going to talk more about the word prescription in a minute, but when it comes to providing medical necessity, we must illustrate how the loss impacts the individual with the impairment. The federal program does not want to prevent people who need help from obtaining it, although it probably feels like that, right? What they're doing is trying to prevent people from obtaining over-the-counter hearing aids. During that call, it was two hours, and we heard that over and over. They don't want over-the-counter hearing aids being dispensed to their members for a variety of reasons. Therefore, in order to support the need, we must document and clearly communicate the challenges our patients are experiencing in their daily lives. I find the easiest way to do this is through a needs analysis or a quality of life evaluation. The one you're seeing on your screen I developed, it works well for me. IHS has them. If you have the distance learning course, they're all over online. Pick something up. I don't think it really matters here. What matters is that you're assessing them as a human and not just the thresholds on a chart. How does this impact them? Use this information and write it down and document it, and that gets shared with Blue Cross Blue Shield. Now, of course, you could have done everything you were supposed to do. You submitted the documents, they were clear, and you're still denied. This is out of our control, and it is not likely to be resolved. However, you can escalate the complaint beyond your state Blue Cross Blue Shield. So let's look deeper into these escalation options. You need to follow the appropriate channels here. Please do not escalate a complaint if you haven't first tried resolutions at the state level. IHS is passing this email on to you so that you can file grievances directly with the Federal Employee Program. However, if their inbox is full of issues they've already taken steps to resolve, they may not be so friendly to work with us on future policy change requests. So handle this email with care. I did tell them that I was speaking and going to give it out, and I think the lady had a visible heart murmur there. She said, oh, please, not on past stuff. And I promised her that we won't email past complaints or past problems. Today, moving forward, if you're getting denials, you've worked at the state level, and they're just not taking it seriously, then go ahead and escalate it. It is important to know that this is not your email contact for all issues FEP-related. This email address is only for policy issues when a state fails to comply with the policy as written in that 005 guideline. An example complaint would be that you have a patient client, they've met all the criteria, but the authorization, let's just say it was denied due to your failure to submit a follow-up care plan. I've had several people reach out and say, now they're requiring a follow-up plan. A description of follow-up plans are not required by the guideline. However, you should realize that standard documentation does require a plan in general. So make sure you've included the basic plan as part of your documentation. For those who have attended previous sessions of mine, I like to use the acronym CHARP. It just keeps me in an order. And I use this one specifically for audiometry. Here's an example of a clear and concise plan. I would say we will submit a prior authorization to the patient's health plan as required by their policy. Once approved, we will place the order for hearing aids and schedule a fitting and orientation appointment. That's a plan. Now, I see a lot of people do notes, and they forget this little tidbit at the bottom. Notice I put the patient's name on here, and I say they acknowledge understanding and agreement with the plan. That's important, and it's often left off. To escalate it further, that would be a complaint to the OPM. That's the Office of Personnel Management. This complaint needs to come from your patient, their member. That's because they're the policyholder. They have the most authority when it comes to disagreeing with the policy. The OPM is the human resources arm for the federal government. This is where policies are written, and according to the Executive Director of the Federal Employee Program, if these guys receive just one complaint or phone call from their member who's upset with a policy, it's a big deal. Therefore, you may want to have a printed material to assist your patient in filing a complaint with the OPM if they need hearing aids but aren't able to obtain them due to bad policy. Okay, on to my number two complaint or issue is prior authorization. Listen, this is going to make it through all of 2024, unfortunately. Interestingly, we met with a large group of the Federal Employee Program, and the Executive Director said, could we have done it differently? Probably. Is it possible we make changes yet next year? Yes, possible. So, you know, let's just hope for that, right? But we're stuck with it. Why? Well, it's hard to imagine from our corner of the world, but your patients, clients, they're allowed to work directly with their health plan for reimbursement. This authorization process is a method of preventing federal money from being spent on OTC products. And this is why I said earlier, you may come to appreciate why they modified their policy. They want you, they see the value in you as a dispenser and they respect your specialty. So that's why this exists. They wanna make sure you are the one providing the service or the product and that you're not dispensing over the counter products. We all know there are some people who are now carrying over the counter. And so there's this little catch there that if you're gonna provide them, how do we know as a FEP program, how do we know you're not gonna bill us for those? What's the old saying? One bad apple can spoil the barrel. So how long can you expect an authorization to take before it's approved? Well, that's the stinker. The law allows them to take up to 15 days. That's a long time. Now it could be less, but I would suggest you make sure patients understand this timeframe. Give them 15 days. I subscribe to the philosophy of under-promise, over-deliver as Todd Byer taught me. 15 days is a long time, but you know what's longer? 30 or 45, because every time they come back and request more information of you because you failed to supply something for them, it restarts the clock and they get an additional 15 days. So this thing could be delayed way longer than you want. So we need to talk through what you need to include with these, but first on a side note, please do not use the little check box that says urgent. As you can see on your screen, urgent requests are reserved for life and death situations. A delay in receiving a hearing aid will not result in unforeseen illness or injury. Now maybe it was tongue in cheek, but I had one member argue with me that a hearing loss increases a fall risk and therefore it could be prevented with hearing aids. So that makes it urgent. It is unfortunate people fall and get hurt, but there's no evidence that the individual wouldn't have fallen if they had hearing aids. So we're not marking this box. Instead, let's do our part by clearly communicating with the authorization department and submitting the required documents. So here's what you need to include along, of course, with the authorization form. You need an audiogram and clinic notes. Don't forget to sign your audiograms and don't forget to sign your notes. Below your signature line, have your typed name. I see that missing all the time. You should have your license number as well as the state you're licensed to be practicing in and also include your NPI. Along with that, as I said earlier, have a needs assessment. If you're not in the habit of completing the needs assessment and documenting your appointment, I strongly encourage you to develop that habit because this requirement is for all health plan participations. Without such, you're actually opening yourself up for a false claim violation. And as I've said many times, just because you've gotten away with it does not make it legal. And lastly, I want you to consider adding the FDA classifications, but we're gonna talk about that a little bit in a little bit. What you do not need is a prescription signed by a medical doctor, a PAC, or an audiologist, despite what you've been told and admittedly, despite what I have told you. And I regret that. I worked with Blue Cross Federal and they said it needed a prescription. And here's why we were told that. I kind of liken this to the old game of telephone, right? Thankfully, FEP has made it clear that most of what we had heard was just misinterpretation. So for those who were told we need a prescription, that was wrong. But you can kind of see why they were saying it, dispensed by a prescription from a licensed provider and within six months of date of prescription. And so there was a lot of belief that you had to have a physical actual prescription. From today forward, if you are getting this response from your authorization department, you have a case to email that FEP policy line, but don't email them on a past policy, just today moving forward. Of course, you can understand this issue reading this. As a licensed hearing aid specialist, I don't write prescriptions. Many of you do not write prescriptions, but I do write orders. My staff wouldn't know how to care for our patients' needs without them. But I realize many of you may not routinely do orders, so I'm gonna show you how I do them and how that applies later on. So here's a look at what I write on a clinic note. It might say updated audiogram or probe mic, and I thought maybe that wouldn't make sense. So I've supplied you with a full note, obviously with a different name on it. You can see at the bottom of it, it says clearly in order in this case, I'm saying that maybe this person has to have reorientation. Oh, what does this have to do with FEP and new hearing aids orders? Well, we have to provide clear communication. In this case, it's my staff. We're gonna get back to FDA, our orders and this FDA situation in just a moment. Hang in there. By using orders, we're gonna ensure that we're not violating our scope of practice. We certainly wouldn't wanna suggest we're medical doctors when we're not. So let's look at the FDA approval. Initially, many states were typing in a hearing aid brand name on the 501k database only to find it wasn't listed. So that's where the denials were coming from. And while I can't get into all of the intricacies of the FDA databases, I want you to know that the states have been allowed to use more than just that 501k database. So you can use a device classification and the registration device listing. So when we submit the information on our authorization, the states are gonna use these to find the hearing aid. And if it's on there, then they can approve it as FDA approved. Personally, I am not gonna leave this in the hands of the authorization reviewer. I'm gonna fill in the blanks for them. And that's where the order comes in. Here's my order for an FEP member. I type order in all caps. And below that, I write the appropriate product that matches my recommendation from my clinic note. But I add a few important words, FDA approved and prescription in the text. I'm gonna include the classification code as well as the registration number. And don't forget to sign it. Now it's important to note that a device listed in this particular database does not really mean it's FDA approved. However, FEHB is allowing states to search this listing. So what's gonna happen if we type in a brand name, it'll come up and then they can click these links to get more information. Now don't let this confuse you. I know we were just looking at Widex and now we're looking at Starkey. I'm trying to give equal time to manufacturers here. So, but I can assure you they all come up the same way. Like the one on the left, you can see that it says an air conduction prescription hearing aid. Whereas the one on the right says it's an over the counter. The registration numbers look kind of like this. I'm not the authority on this list. It only selects a few products from a variety of manufacturers. I would suggest you use the link I provided on the previous slide to enter the manufacturer brand name and then use the search and find option to ensure you're using the correct registration number. I would have suggested you ask your rep, but frankly, I called several and they did not know what I'm talking about. So that's not gonna be helpful. Also realize you don't have to do this. You can submit your authorization with the brand name and leave it up to the authorizer to look up and find. But for me, I wanna smooth those bumps out and get this moving as quickly as possible. So that's why I'm going to use it. Also as a side note, if I can get an official list together, IHS members will receive that list as a benefit of membership. Additionally, you can include classification codes. You could do one or the other. When you type in prescription hearing aid in this link, you'll get three codes. One of them's over-the-counter self-fitting hearing aid. And so these are the two that classify under prescription. Be careful, look to the far right. The device class, ESD is a class one, OSM is a class two. So don't just look to the device terminology. Before we close, I feel it's really important that I highlight a couple more things you should be watching for. There's additional guidance for those who've had hearing aids for more than three years, but less than five years from their previous claim. This means if you have a patient who's had a significant decline, 15 decibels, in their hearing, and they're no longer able to benefit from the hearing aid they have, you could submit documentation and try to get hearing aids covered under the new guideline. Be prepared, you have to illustrate this need under a microscope. And really, I have a hunch that this is where some of those plan denials come from, because they were saying that you had to have a follow-up plan. If you look here, it says that you have to demonstrate need and you have to show a follow-up plan for assessing effectiveness and outcome. So if they are an initial hearing aid wearer, have never had a claim on hearing aids before, or they're greater than five years, this doesn't apply. This is specifically for more than three, less than five. And if that's the case, you do have to have a follow-up plan. If they deny it with a follow-up plan when it's not necessary, this is when you'll wanna email the FEPP policy. Of course, only after you've tried to file an appeal with your local Blue Cross. And I realize that I've mentioned reporting to FEPP and OPM a few times, but I also wanna suggest that maybe you wanna report some of this to IHS as well. If it's a recurring problem, we're a big voice and I personally wanna continue to monitor their compliance here. Finally, there are items that are not covered. I've heard people use their patient's $2,500 benefit towards accessories when maybe they didn't want or need a new pair after five years. They told me they were doing this using miscellaneous codes, miscellaneous hearing codes, or just the V5 299. To be clear, those are not covered. And billing for them, even if they are paid, are false claims. All you need to do is reflect on the Brand X case to see how that plays out. Just don't do it. And that's it. I think we'll put it back to Sierra. Thank you so much, Samantha. That was great. I know, folks, it was a ton of information. I'm seeing lots of questions come through already, which is great. So Samantha, you know how this goes. I'll give you the questions. We'll get through as many as we can. Folks, put those in the Q&A box and we'll see how many we get to. So our first question here, Samantha, is from Mike. Mike says that on the Blue Cross Blue Shield FEP website, patients can download their own reimbursement forms. So if they pay the clinician out of pocket and then they submit that form themselves, is there any need to complete the prior authorization? Mike, I've heard that question before. And yeah, it's logical. We're out of network. We can have them pay no dice. I'm sorry to tell you that this prior authorization, it lives at the policy level. And our patients are aware of this. They know they are required to get prior authorization first. So if we played your scenario out, when they try to submit the claim, it wouldn't be reimbursed. They wouldn't get their money back. The best thing we can do as providers is tell them that their policy requires this and make sure that we help them be in compliance as well. Great, thank you very much. Next question is from Dorothy. So Dorothy's asking, what about patients with mild or normal hearing but an auditory processing disorder? We know that hearing aids combined with direct audio input provides improved hearing for these patients. So do you have any thoughts on whether that would be approved, how to get it approved? It's definitely not. Yeah, so here's the thing. As we were told in that meeting, listen, if you have a person with need, we want to get them the product they need. That's not our intent. What we are asking you to do, and by we, I'm saying what Phep said, we're asking you to tell us why this person needs hearing aids. Think back to what I said early on, 40dB, this is a hot topic, blood boiling for me. It took a little bit for me to try to calm myself down on that meeting when they said they weren't going to change that right now until I started presenting some cases. And they said, oh, right? Because largely we're violators of this too. We look at an audiogram and we almost think the thresholds say something or the majority, and that's not true. An ability to understand is critical. So all you need to do, and I say that like it's easy, you've just got to support your recommendation. Great, thank you so much. Good question. Next question is from Martin, and it's actually a two-parter. So I'm going to give you the first part first. He's a new private practice owner in Vermont. And his question is, does the federal program recommend hearing instrument specialists or state licensed hearing aid dispensers as hearing care professionals, or does the fed only recognize audiologists? So that's the first part. Okay, well, first real importantly, they said your scope of license allows you to do this. Remember we were saying prescription, prescription. The word prescribe is to order, right? It's to say there is a need for this. And so we are recognized. We're recognized in the states we practice in and the federal employee program itself recognizes our scope. So absolutely, I just don't like the term prescription. I don't want us using it personally because I think a larger group is going to have challenges with that. So I'm personally using order, but yes, you can be assured that they recognize you. Great, thank you. That's great news, obviously, for everybody on the call. Second part of the question from Martin, what exactly is the process for submitting a prior auth? Is there a state-specific website or a standardized universal site? Martin, thanks for that question. I don't know how many of you on the call are IHS members or how many, I hope all of you, frankly, but I don't know if you have the IHS 360 app. I had in the beginning put some little things out on that app. And so one of the things I put out there was the contacts for your local Blue Cross per state. So there's a prior authorization department in the majority of states, not all of them. Some just, you have to go through customer service, but if you're a member, download the 360 app and then you can access that. I wish I had thought about putting it up on here, but those are your numbers. And then what you need to do is contact that department and see, do they want you to submit your own generic prior authorization, as quite a few states do, or some states have a prior auth made for you that you need to utilize. So you've got to ask them which one it is. I'm not sure in Vermont particularly, but we can certainly help if you can't find the answer. Great, thank you, Samantha. And we're going to drop some information in the chat box about downloading the IHS 360 app for those of you who haven't done that yet. Majority of people on the webinar are IHS members, so that would be available to you. You can learn more about joining and the benefits of membership at IHSinfo.org if you are a non-member. I also just want to acknowledge out loud, we've gotten several questions about having access to the slides or recording after the fact. So you can also follow the link that we have dropped in the chat box for that. So the slides are available to you right now to download as registrants of this webinar and the recording will be available, we're hoping like in the next couple of days for you to access, we just, you know, the video renders, we edit it and then we get it posted back up for you. So that will be available for you too. Next question is from Renee and this might kind of piggyback on what you just said, but I'm going to ask it out loud because I don't know for sure. So Renee asks, Samantha, are we submitting all this information in Availity? Which sounds like the name of a software or something. Yeah, Availity. Yeah, in some states, in fact, require that. So there are portals. So for some that may not be familiar with Availity, maybe you're still doing paper claims. Availity is a clearinghouse portal that you can use to submit that stuff through. Some attachments are difficult when using some of those portals, but if you're in a particular state that requires its use, then absolutely you have to go that route. Perfect, thank you. Thanks for the question, Renee. Okay, next is a question from Kim. Kim says, so what do we do with the patients who have been declined already because they came in last month. We can't appeal it. And they said, we can't start over with a new pre-op. So are those patients just stuck? What do we do for those people? Yeah, so here's the thing, timeframe is gonna matter, right? So I would suggest two things. Number one, it's odd that they said you can't appeal it. Right? So what I would do first is take that denial information and call them and say, I have since learned, right? Maybe they denied it because you didn't hit 40 decibels. Well, then you gotta show why they need it. Maybe they denied it for one of the things we covered prescription, which was untrue or unfounded. And so if it was for one of those reasons, I would reach out to your local Blue Cross and say, I was just on a webinar and I learned that this is not true and try to go through your local carrier, give them the opportunity to reflect on the new training they've also had to correct it. If they don't do that, then please, A, let me know. But also, you know, I'm gonna be a stickler for this. They should be as compliant as we have to be, right? And I think everybody agrees to that. But then you might need to escalate it to the policy. And that was the email we provided you earlier. Again, there's a lot of circumstances that could change these things. So I can't give too much of a blanket. It depends on what that denial reason was. Okay, great, thank you. Next question is from Linda. So Linda says, can you give us a quick synopsis of exactly what we need for prior approval? Her understanding is audiogram, the clinical docs, which include the chart notes with recommendation and impacts to quality of life and needs assessment. Can you remind us what else has to be included with that prior auth? Yeah, so, you know, clinical documentation, I wanna back up and remind you that it's not a quick paragraph. And it should explain first and foremost, the chief complaint. Why is that patient calling your office and requesting a hearing test to begin with? What are their challenges? What's their history? What environments are they in? Are they currently working or are they retired, right? So you build this case for a need, and then you do an assessment. Of course, that's your hearing test. And you describe very clearly what the loss is. Make sure that you're saying your SRTs are in agreement with your pure tone. So you can say it's a good, reliable test. Furthermore, you have to have a recommendation in there in the plan. That's separate of the order. I am strongly suggesting that everybody include or attach an order from you as a professional that says the generic terms. You know, Oticon Real 1 really means nothing to the authorizer. What they need to know is that they're an FDA approved prescription hearing aid. And so you could do that, or you could add those two FDA classification registration numbers that I had previously suggested. You only need the, really quick, a reminder, you only need the follow-up plan. If you have a match that's greater than three years, less than five years, then you have to start to explain that you're gonna do real ear measurements and all of that fun jazz. Great, thank you. A little bit of a follow-up question from Linda, which is about logistically submitting the claim. She said that availability does not allow documents to be attached to the claim. So how could they submit all that documentation? Yeah, so you have to reach out to your local and ask them. You know, through our clearing house, we are able to attach. So I know how mine works, and I wish I could know everything about everything, and man, that would be annoying. But I would suggest you just have to reach out to them and say, how do I get this stuff attached? Great, thank you. Okay, next question is from Kimberly. She says, so if I understand it, hearing aids can be replaced under five years if they meet the criteria listed for changes in hearing, et cetera, with all the proper documentation, of course. Is that correct? It is, and if you reflect on the slide, they must have a minimum of a 15 decibel change at one frequency between 500 and 4,000 hertz. So that's the minimum guide. If they don't have that change, it's really out. You can't prove it. But also, you know, you've got to think, how do you prove that this hearing aid no longer meets their need? And sometimes that's through circuitry, showing that the circuit is no longer powerful enough. We've got RIC products. Manufacturers make great products where you can change out the wire to a higher power receiver, embedded receivers. And so you might not meet the need of buying a whole new hearing aid, but you may be able to make the case that the embedded receiver is expensive, and maybe they'll pay that difference, but you got to prove it. Great, thank you. Next question is from Kayla. She's in Tennessee, and she said that our understanding was this was going through a third party, i.e. True Hearing, for services to be covered. Do you have any comment on that? This does not go through True Hearing. A lot of state plans. So we got Blue Cross Blue Shield, which is an independent company in different states. So using my example in Wisconsin, I have Anthem Blue Cross Blue Shield. That's separate of the Blue Cross Federal Employee Program. And so for any of my patients, I've got to bill through the local Blue Cross, okay? Totally separate then, I, who also happen to be a Blue Cross Blue Shield member, I have access to Blue 365, which is nearly in every state, and True Hearing. So that's how Anthem, my local, manages access to discount, not a benefit. That's not the same as the Federal Employee Program. You do not have to go through there. There is an important caveat, and we know this is to be true with other federal programs. So we'll just say, sometimes you will make your verification of eligibility or benefits and eligibility phone calls. And they will tell you the benefit is through UnitedHealthcare Hearing, True Hearing, whatever it is. And this misleads people to think that they can only go through that program to get the benefit. It's in addition to, and what it means is that if you go through, because she used True Hearing, I'll use it, if you go through True Hearing, which already reduces your out-of-pocket expense, and then you can use that $2,500, your patient could end up with little to no out-of-pocket costs. That's different if they came to me, who does not participate in True Hearing, it's $2,500 off of the total. And so they are gonna have out-of-pocket expense if they don't buy hearing aids under that $2,500 limit. Hopefully that clears it up for her. Thank you. Okay, next question is from Anonymous. Is there an official authorization form that gets filled out for the clinical information as far as the supporting documentation goes? So I think like, is there some kind of master prior auth form that can be filled out that contains everything that's needed? I sent one out in the very early days, very early. It's generic, I actually included it on the IHS 360 app. So look there if you need a generic one. Great. The reason that went out is because there was something like nine or 10 states that we knew said, use your own form. And so I just created it so that those states had something. Do not use that form if you are in a state that requires the use of its own prior authorization. And you know that by calling those numbers and your local Blue Cross and asking them. Okay. So again, I wish I knew every single state, but I don't. If you do have problems with it and you're not sure, just reach out, that's what we're here to help you with. Great, thank you. And just a reminder again, the information about downloading the IHS 360 app is in the chat box for you. So IHS members that is available to you as a resource, which is where Samantha posted that generic form. Next question is from Brenda. So for current denials that occurred prior to today, do you have suggestions because, and I'm gonna just quote, I'm gonna read what she wrote exactly cause I don't wanna misspeak. She said, FedBlue is stating the peer to peer must be with a medical professional that can write prescriptions. Like an MD, PA or NP, at least in Pennsylvania. Yeah, well, we know that not to be true, right? We don't have to have someone with a prescription. Now, if we submit an appeal, we say, nope, this is a wrong denial. We believe it to be wrong. They are going to do a peer to peer where you get to meet with someone who is not a licensed hearing care professional, who you get to explain and make your case to. That's how it works. But if the denial came from something that we know is not an accurate policy, then we have to get it fixed. And so the first thing that FEP wants us to do is to reach out again to our local and say, we had this situation. We were on a webinar. We've learned that there's been new training materials. I want you to relook at this. And if they are unwilling to check it, I want you to then take that to the policy and say, I tried local and they're not willing to do it. And that's the email address that we're using with CARE, right? That would be a perfect example of when to use it. Yeah, yeah. Very good, thank you. Next question is from an anonymous viewer who says that hearing aid dispensers cannot be a network provider, but you must be an in-network provider to get pre-approval. How do we get around this? Okay, so this person, please go to the IHS and get the managed care guide. Please watch some of the other webinars. IHS or hearing aid dispensers can absolutely be in-network. That's discrimination against our license type, but there's some group of people out there saying, hearing aid dispenser, you cannot do X. And it's just wrong. And it's frustrating that we still believe this. So that's number one. The question two, there was a backend part to this question. What was it? If you, but we know that you have to be in-network to get pre-approval. So how do we get around this? So they're saying we can't be in-network, but you have to be in-network. So what do we do? Yeah, so you don't have to be in-network. The $2,500 benefit is at the policy level. It has nothing to do with you as a provider. It has to do with the member. They have access to that benefit and they can go to in-network or out-of-network. It's their benefit. The prior auth is making sure they get a good quality product from a licensed provider. So you don't have to be in-network. If they're telling you, you have to be in-network, now we have a plan issue. And then I will release that email separately. If you're having some issues with that, please reach out to IHS. And we'll share the email shortly that you can reach out to us if there is something totally bonkers that you need help with. Okay, very good. Thank you. Next is just a PSA from Anthony who wanted to let folks know that for Illinois, he was told that you could not submit the pre-auth through availability probably because of those documentation issues. And instead you need to go through bcbsil.com. So if you're in Illinois, bcbsil.com. Thank you, Anthony. Next is Melissa. Samantha, what if anything can be done for somebody who purchased on January 2nd of this year and the prior auth was not requested? The prior auth was not requested. So my follow-up would be you're suggesting that $2,500 reimbursement was given, right? So we really need to understand if this person is saying they collected the money upfront and the member did get a benefit or it just went through without issue and, or we're still waiting for benefit. So we need to specify, did the patient just pay for their hearing aids? Now they realize they have a benefit. They're wondering if they can go back or did you fit them with hearing aids, filed the claim, got paid, but now you realize you should have done the prior auth. So could you maybe give us a rundown of what the answer to both of those would be quickly? Yeah, so if we submitted a claim and we didn't get a prior auth and now we realize, oops, that claim is gonna come back denied, I don't have the best answer. It's gonna have to go through local that wouldn't, shouldn't technically get paid. If you got paid for it, they made the mistake and didn't require the prior authorization, I would just watch and monitor that. Sometimes what happens in an audit is they realize they made a mistake and released fundings without following the policy and cough, they request an overpayment refund. That happens. Thank you. And is there anything to be done for a patient who I'm assuming, I think no, but who paid out of pocket and then later they realized they had a benefit. There's no way to go back, right? No. Yeah. Great, thank you. Well, the trial period, if you're in trial period, you return the hearing aid and then start over. So, right now we're early on. So we're talking about the fact that we're six weeks out. I would work with the manufacturer. Don't falsify dates. This is people making up things and saying a new fitting. Listen, own it, work with your manufacturer and then maybe return the hearing aid for credit and do a refitting because you could possibly do that to correct it. Okay, thank you. I'm just looking through because we only have a couple of minutes here. So I'm gonna go to this question from Sarah. Was there any discussion or do you know anything about requesting hearing aids with no hearing loss but they have tinnitus and you think they could benefit from the hearing aid? Yeah, so tinnitus is not addressed. Remember the 40 DB rule. And so that person is going to fall under the consideration clause. You would need to make a pretty substantial argument which we're used to, right? With tinnitus patients, you get people who come in and say, I don't want a hearing aid. I just have tinnitus and I need help for it. So go under the consideration clause and explain it. I think you've really got to do your homework. You got to have access to a lot of the, you know, not just THI, but the other tinnitus systems out there where you could show the consequence, the lifestyle consequence of that person's suffering from tinnitus and needing devices. But certainly that's gonna be an uphill battle. Thank you. Next question, probably the last question. This is from Zach. As to that in-network versus out-of-network benefit issue, we're being told that basic Blue Cross Blue Shield FEP plans have $0 in out-of-network benefits. However, standard Blue Cross Blue Shield FEP plans have the 2,500 to use either in-network or out-of-network. Is that correct? Yeah, there is a webinar. We have it. Man, I wish I knew what title this was under. I've spoken on it quite a bit. And one of the things I highlight here is that they have three, not just the two you highlighted, focus, basic, and standard. Okay. So two of the three have the 2,500 benefit. They don't all have it. This is speaking of the plans that actually have the benefit and when they do, it's in or out-of-network. That's a really good question. And thanks for that clarification. Okay. We're just speaking of the plans that have it. Thank you. Okay, thanks, Samantha. I'm gonna give just a couple PSAs on the questions that I'm seeing that we didn't get to because I see some things that we covered already. So I just wanna say a couple of things out loud again. So you wanna make sure when you're submitting your prior auth, you're including the full audiogram as opposed to just stating the PTA. That's a question that I'm seeing. The question again about if a patient submits a claim for reimbursement, does that cancel out having to get the prior auth? It absolutely does not cancel it out. You still need to get the prior auth. Samantha's smiling at me because she'll make a coder out of me yet. And let's see, I think that's it as far as questions that we've already addressed. So Samantha, if you wanna hit to your next slide, there's an email address there. So folks, if we didn't get to your question today, please send the IHS team an email so that the Managed Care and Compliance Committee can review and respond to any of your questions. So that is of course all the time that we have for today. Thank you, Samantha, as always for your partnership and for sharing this valuable presentation and for your advocacy within this system, right? To even get us this information to be able to share today. So again, contact us at advocacy at IHSinfo.org for any further questions that you have. Just a reminder for folks as well, you can receive a CE credit for this webinar. Visit that webinar webpage that is in the chat box. At that link, you will take the quiz to get your CE credit. You can access Samantha's slides, which include those device registration numbers that I saw a few questions come through about. So the slides are up there as well as the quiz for you right now. The recording of this presentation will be up there in the next couple of days. You can go to the IHS website, IHSinfo.org to purchase the managed care guide that Samantha was talking about. And within our education portal, education.IHSinfo.org, there are additional webinars about managed care participation and what that might look like in your practice. So all those resources are available free to IHS members. So please take advantage of them. Thank you so much again, folks, for joining us today and we'll catch you at the next IHS webinar. Take care. Bye-bye.

Blue Cross Blue Shield Federal Employee Program

prior authorization process

coverage considerations

clear documentation

audiograms

clinical notes

needs assessment

updated guidelines

policy changes

medical necessity