Welcome everyone to the IHS webinar, Unveiled Managed Care Guide. I'm your moderator, Sean Drake, IHS's Director of Government Affairs and Advocacy. Thank you so much for joining us. Before we get started, I want to share a few housekeeping items. Please 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. 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 www.ihsinfo.org slash webinars. A link to this page has been added to the chat box. The slides for today's presentation can be can also be downloaded from the same page. Feel free to take a moment now to do so if you would like to follow along. 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. And now on to our speaker. To introduce the new Managed Care Guide 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 initiating the best practices for hearing care professionals and patient education. Samantha began her career as an occupational hearing conservationist in 2001. After developing endolymphatic hydrops 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 audioprosthologist designation from the American Conference of Audioprosthology 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 general conversations 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. Thank you, Sean, for that kind introduction. I'd like to start by saying that this guide would not have been possible if not for the dedication, knowledge, and countless hours these folks you're seeing on your screen committed to this project. And had it not been for the support and encouragement from IHS, especially Executive Director Alyssa Parity, this product would have never gotten off the ground. I also feel the need to prepare you that this webinar will provide you with information on what is inside of the new Managed Care Guide and will give you information on how to apply some of the most complex aspects of participation. It is not intended to replace, nor do I unfortunately have the adequate time to get into details necessary to solve most of your day-to-day challenges. That said, some of the questions people have been asking need to be addressed now, and those are the aspects of the guide that I've elected to show you today. Okay, ready to see it? Ooh, ah. All right, but wait, wait for it. This guide has an electronic version as well as a paper version. Okay, so maybe you're not as excited as I am, but that's because you don't know what's inside of this thing yet. Of course, we have to begin with the basics. I know, it sounds kind of boring, but I want to put it to you this way. You know when a patient walks into your office and they list all these environments they're struggling in and you just know they're being unrealistic, right? Well, for me, teaching insurance is a lot like that because colleagues often want me to give them answers without any historical content, background, or any education. The fact of the matter is, without knowing where the information is or what the rules are, it would be much like the old proverb, give a man to fish. We need to look at some important basics that are outlined in the guide so you know how to apply the information. That's because when something changes, and I guarantee it's going to change a lot, you'll have enough information to make an informed decision on how to proceed. First up, plans are not policies. Plans are merely the outline of an individual's benefit plan. Two of your patients or clients may receive their insurance from the same employer, but have different plans or policies, and understanding this distinction is a necessary aspect to your success when you participate with managed care. One thing the committee felt was important was to delve into the sources of coverage, like what's the difference between an entitlement program and group health? We wanted to outline the different types of providers and vendors health plans typically contract with. By doing this, you are in a better situation to get your benefit and eligibility phone calls correct. My ability to understand this structure allows me to get within $20 of an expected payout. Now, I often hear colleagues complain that insurance never pays what they say. However, I would argue that they do. We just typically misunderstand the application of those funds. Now, it all starts with the card. Now, it all starts with the card. Every card you see, or that patient who walks in with the card, is going to give you clues as to what type of plan structure they have. One big mistake I've seen is where a practice sees two cards. They appear the same, usually you know that's through an employer, and you falsely assume that those two patients have the same benefit. Again, this is why basics are so critical. Most plans offered a tiered policy where members can elect coverage options. Think of that yourself. Through your employer or history of obtaining benefits, you got to look at what your options were. And most of the time, we're choosing that based on out-of-pocket expenses, rather than looking through the benefits. Now, if you have a chronic disease, you might say, I'm a diabetic, I need to know how this covers. But almost always, it's based on those out-of-pocket expenses. And this is true for most employer funded programs, but it occurs with entitlement programs as well. Case in point, we all know this card, right? When you see this card, you know the patient has a $2,500 max benefit, and it's available every five years. I hear it all the time. It's changed from three to five years. That's how every Blue Cross Federal plan works. You're going to learn in a moment that's not true. What you cannot tell from this card is if your patients are eligible for new hearing aids, right? Please do not assume that just because your patient is not wearing hearing aids, or maybe they told you that I had some, I returned them. Don't assume they're eligible. That's a costly mistake for both the practice and the patient. Now, why is this PPO acronym so important? Well, they cover and they allow, excuse me, in any willing provider clause. These plans accept any provider who meets the condition and agrees to the terms of the PPO contract. If you notice, while similar, these cards tell you the specific option the member selected. See those words inside of the U.S. outline? That's different than the PPO's. Well, these are not Medicare plans, and not all of these plans have a hearing aid. Some of you may be thinking I just gave you inaccurate information because you often hear that these plans go through a discount plan. That's not always true. As an additional benefit, FEPP members may elect to go through a provider who participates in third-party discount plans because it reduces their out-of-pocket expenses. That's a choice, not always a requirement. That's a choice, not always a requirement. I happen to have a Blue Cross plan that does require me to go through a discount, but again, you've got to know how the plans work and don't apply one to another. Did you know that FEPP has a Medicare Advantage plan that does not cover hearing aids? That can be a costly error, too. The point of highlighting Blue Cross Blue Shield is that we consistently hear stories of people who misapply benefits from one patient to the next, and this is a major carrier who offers consistent coverage throughout the United States. And while the guide does not lay out every plan in detail, it does give you the tools you need to understand how plans operate so you don't make these costly errors. The details in the guide help readers understand distinct differences between plans to prevent misinformation. For example, commercial plans do not function the same as Medicare plans. And did you know due to new price transparency legislation, plans, pricing, and coverage details are actually available online? So while you're sitting on those long holds to determine eligibility and benefit details, you can often obtain some great information through Google. Maybe not always trustworthy because you might get old data, but you can find some of the current plans on there, which is pretty great. There's a ton of valuable information written on TPAs in this new guide. By understanding it, practices will be far better equipped to navigate the many challenges and frustrations providers are finding when working with TPAs. And while I can't get too far in the weeds with them, I do want to give a few highlights on the subject. First things first, we need to stop referring to every discount vendor as a TPA. In fact, when my practices does a B&E check, we ask if they use a third party vendor for hearing aid related benefits. That's because I want to speak the language of the person who's on the phone. TPAs are organizations contracted to offer operational or administrative services to a health insurance carrier. Not every one of those discount plans are true TPAs. Some are just discount plans. TPAs have been around for decades. This isn't new to health care. 60% of workers in non-federal plans are administered by TPAs, and that market size is growing. I've heard it's supposed to double, so it's going to get big. As I mentioned moments ago, they're more like vendors to the health plan. A third party payer is any person or entity that's not your patient paying for the bill. I guess my beef with this is the fact that we've now begun calling discount plans third parties. In an effort to help you understand why this is problematic, let's talk about the different types of third parties. There are third party payers. These guys are the health plans or your insurance carriers. They're required by law to manage their members' health care expenses. They will almost always contract with third party administrators to manage some or maybe even all of the plan. Discount plans are vendors contracted to extend a discount in lieu of or in addition to the plan's allotted benefit. They may administer the entirety of the members' hearing benefit or only serve to secure discounts to the plan. Administrators, as I just mentioned, are contracted to manage specific aspects of the plan's operation. There's an incredible amount of behind-the-scenes work that's required to run a health plan, and outsourcing some of that work is just genuinely necessary. I don't know about you, but I've been short-staffed, and that's another reason that I think that it's going to double by 2030. Some of that outsourcing could be as simple as claim review or auditing. They may even handle the billing of premiums to plan members. That's what third party administrators actually are. One of the day-to-day functions that is outsourced are organizations hired to save health plan and the patient money. They're repricers. I'm not a fan, personally. You'll see that. They have a huge impact on your bottom line, future claims, and the future budget they allot for such products and services. If you get a fax from one of these companies, you will absolutely want to understand the impact of their proposal to you. This information starts on page 10 of the guide, and inside that guide, we've actually included a case scenario that helps you understand the impact of the proposal. Actually, a real case. It's not a scenario. It helps you understand what decision-making, your process should be, and prevent mistakes, costly mistakes. Page 12 of the guide gets us into the nitty-gritty of participating with health plans. Throughout it, we dispel some common misconceptions about dispensers and participations, so I want to clear up two of those right now. Dispensers are allowed to bill Level 1 CPT codes. We'll talk about that in a bit. The most dangerous one, however, is this continued idea that dispensers aren't participating in Medicare because they're not billing Medicare directly. Wrong. The moment you bill any Medicare Advantage plan, you are required by law to follow the same regulations as if you were billing Medicare directly. That's because, well, if you want to understand how that system works, you're going to have to get the guide. That's way too heavy to get into on this webinar. Are you wondering why I just said the failure for dispensers to recognize they're participating in Medicare is dangerous? Here's why. When we think about Medicare, as it relates to us hearing professionals, we tend to split Medicare into its parts. We think of it as A and B direct billing, as something only audiologists can participate in, and Part C, something dispensers are allowed to participate in. After reading the guide, you'll see that it is one system regulated by the U.S. government. Therefore, those who wish to provide any care to Medicare beneficiaries must follow all the regulation as if they're billing Medicare directly, including having annual fraud, waste, and abuse and HIPAA training. You must verify all of your providers that are seeing any of those patients are not on the OIG's exclusion list. And there are many more things, but those are really important to understand right now. To be clear, your patients who have a Medicare Advantage plan are still Medicare beneficiaries. If you've attended any session of mine where we've discussed some of this previously, then you know Medicare, the government, is paying those Advantage plans every month to manage the beneficiaries' health care. And when the government pays money, they're going to regulate their spending. Therefore, dispensers are required to follow all the state and federal laws set forth by those agencies. And while we're on the Medicare topic, the guide has an amazing appendix. I'm biased, of course, but it's amazing. If you're frustrated dealing with a supplemental carrier who refuses to pay until they receive that Medicare denial, we have two sample letters that'll help you get through that. Oh, the joys of compliance. Listen, the guide would not be helpful if we didn't put a good chunk of information on keeping you and your staff compliant. After all, we are the Managed Care and Compliance Committee. This guide spells out each of the critical laws and is meant to help the readers understand how they apply specifically to our profession. Page 25 addresses HITECH and the HIPAA Omnibus Rule, and they're so often overlooked. In some cases, these aren't even known. A lot of my colleagues that I'm speaking to don't know what I'm talking about when I bring these up, and they think they're only for large hospital systems. That's not true. So I want to step into this just a moment to give you some insight on why this is critical to you today. I doubt any of you are unfamiliar with HIPAA. However, I do commonly hear people say that HIPAA prohibits the sharing of their patient's health information. Like, you know, when you give that notice to patients, sign it and say, this says we can't share your information. That's wrong. That's not true. Hopefully you're not doing it. HIPAA does not prohibit the sharing of PHI. Rather, it outlines when and how covered entities can share it. Now, high-tech is a very important act. It enhances HIPAA. It expanded covered entities to include business associates and encourage the use of electronic health records. I think I need to make sure you all understand what that means for you. You are required by law to have a business associate agreement on file with every one of your vendors. That includes manufacturers. Manufacturers are now covered entities and they are required by law to tell you how they will use and protect your patient's information. These business associate agreements are to be placed in your compliance plan. I have yet to audit a practice that has a compliance plan on file. FYI, that's another document IHS offers you. Failing to have a compliance plan on file is dangerous. The Omnibus Rule of 2013 strengthened the privacy and security protections under HIPAA and high-tech. It expanded what would be considered a breach. This rule is really important because it outlined a tiered structure for failure to comply with the acts, as well as ensures patients have access to their electronic health records. Together, these rules outline how covered entities are required to protect privacy, keep PHI secure and notify patients in the event of a breach. There seems to be an idea that if one doesn't know about a law or makes a little mistake that they're not gonna be held accountable for it. The HIPAA Omnibus Rule removed the cap on fines and modified civil monetary penalties to allow annually for inflation. Therefore, you won't find this information in the guide. It talks about it as a general rule, but you won't see these numbers in the guide because it literally changed three times from when we started writing it. Full disclosure, I wanted it in there, but Doug Lewis, who is incredibly smart, said we can't afford to put it in there. Inflation is gonna change this, and it has changed it to this tune. 1.5 million to 1.9 million. Those are big changes in just three years. And do you happen to notice how much higher the fines are now from when we started? Yikes. These fines also are applied per violation, and without having a compliance plan in place and following it, one would have an incredibly difficult time trying to suggest they were making any reasonable effort to protect privacy and security of their patients, if they were found to be in violation, of course. It's a big deal. And I do have to scroll here just a moment because this is way too often overlooked and is also not in the guide. That's because this document cannot replace the compliance plan guidance. So again, if you have not downloaded that IHS resource, please do immediately after the webinar. I wouldn't really begrudge you if you were online trying to find it right now, frankly. Just remember the guide lays out the foundation for everything you need to decide if you wanna participate and how the system works. But should you decide to engage, you need to have a compliance plan too. We are all HIPAA covered entities, which means we're required by law to perform a risk assessment to determine our current security risk and employ administrative, physical and technical safeguards. Further, each of these safeguards must be outlined in your compliance plan. Now, what is in the guide is information on how you can access your annual HIPAA training and all HIPAA training should include the information on these three critical aspects. All right, back to the guide. Another important compliance subject, contracts. I know you're all so excited about this part. I'm one of those super odd people who loves contract law and because so many people don't like it, they just push those contracts aside, but then they often struggle to understand why upgrading a patient in their technology results in being so grossly underpaid. So buckle up folks, this is where it gets interesting and maybe where you feel it was worth joining this webinar. When I first started auditing practices, I asked for their contracts and in almost every single instance, I was given the fee schedule. That is, if they could actually even locate it. Hearing care providers routinely look at this fee schedule as if that's all that matters, but if it were all that mattered, the carrier wouldn't send nearly a book of texts that outlined our shared responsibilities. Before you sign an agreement, or in this case, if you've already signed one, be sure to go back and look at those contracts. You have to know what you're getting into. Now, what you're seeing here are three stipulations that I had in one of the contracts I was sent. There is no way I would agree to 24-hour phone access. Can you even imagine what wax filter issues or emergencies would come up? They're not gonna die if they can't hear. It stinks, but I'm not giving 24-hour phone access. So I just went back to the carrier, explained that, and had it stricken. You may be surprised to learn that quality improvement and patient safety are in almost every contract. Remember that HMO Act of 1973? Well, that act mandates that managed care plans control cost, quality, and utilization. The easiest way to control quality is to force the practice to have measures or metrics to ensure it, monitor it. They may be called different things, but they're in your contracts. You wanna know how to handle the requirements? Get the guide. Speaking of controlling cost, the way plans do that is to limit technology of hearing aids by covering product that meets the minimum needs of the patient. I want you to think of this similarly to a wheelchair. If a patient needs a wheelchair, but wants an all-terrain chair or a motorized chair, the carrier is gonna need to see supporting clinical documentation that warrants that upgrade. As providers, we think of this much oversight as being unfair or highly restrictive, but frankly, that's because we're not paying the bill and we have no regulation requiring us to limit their out-of-pocket spending. That's how it is, but upgrades can happen in certain circumstances. And when done properly, you can get paid. Lord knows I can't afford to work for free. What you cannot fail to investigate is both the plan and your contract. Now, if you don't have a contract, there are gonna be some differences here. And again, you need the guide to help you walk through that because we don't have the time. This is an overview. But if the patient's plan allows upgrade and your contract prohibits the upgrade, you're gonna have to write that upgraded amount off. There is a caveat. In some cases, you can get authorization and support your case for making the recommendation. Just make sure you have approval in writing from the carrier before you submit that bill. If the contract allows an upgrade on the plan, you will still need to justify it through charting, but there's no contractual reason you're precluded from making the recommendation so long as it's medically appropriate. Be sure to use proper coding for this, and we will talk about that. If the plan prohibits upgrade, but your contract allows it, their plan supersedes your contract. You have to follow their plan. That's a stinker, and that's how you lose money very quickly. And finally, if both the plan and the contract prohibit an upgrade, fit what's covered by the plan. Do not make the mistake of allowing the patient to pay you the difference privately. On this note, I had an account reach out and tell me they only billed the allowed amount. She said, well, we have a contract with the carrier, so we just put the claim through for the contracted rate. We bill that to insurance, and then we collect the remaining difference from the patient. That's insurance fraud. Do not do that. One of the examples written in the guide outlines a patient who is electing to upgrade a product. Of course, that's in far better detail, but let's just go through it. The patient's benefit plan has an 80-20 coinsurance. They have $500 remaining deductible, and it allows for $2,000 on a pair of hearing aids. Now, your practice, on the other hand, charges $3,000 at a basic entry-level product. Let's proceed assuming your patient wants the standard technology, that $4,000 amount, and their audiogram and their lifestyle supports the need for it. Here, we're able to look how this plays out when the provider is in-network. The contract allows $2,000 on the code, and the patient has selected a $4,000 product. That means this organization is going to pay or take an immediate $2,000 hit due to their contract. It makes the contract look bad, doesn't it? And once adjudicated, it becomes clear that the organization is the one that paid the most money on the claim while the patient paid the least. I think this is what drives most people nuts about insurance. Practices are signing contracts without fully recognizing what the allowed amount will mean for them and their bottom line. In such cases, they continue to write off more than they can possibly make, or equal amounts in this case. Now, on the right side of the screen, what we're seeing is what happens when we properly utilize an upgrade code. While this does still require a write-off, it's half of what that other circumstance is. Please note, in order for this to work, the hearing aid pricing is based off of the basic technology. See that new charge? The charge on the left was 4,000, and now suddenly the charge on the right is 3,000 with a $1,000 upgrade amount. So we'll get into that. You might actually look at this and feel the contract is bad because it doesn't even cover your basic hearing aids. While another person may argue that your prices don't allow for a product line that has technology covered by the contract. As long as you review the contract and aren't working harder than you're getting paid, I say do what works, as long as you stay legally compliant. Of course, that's a big deal, right? When one receives a fee schedule from a carrier, careful review of the practice's product line is necessary to determine if the carrier's budget will cover any of the available products. The issue with the previous scenario we discussed is that the price clearly didn't have a technology available that was 100% covered by the carrier. And I find this to be true in so many cases. It's okay if you're limited to one brand. Most brands have a wide range of product options. Just be sure to look at each and select the technology covered by the contract's fee schedule. Pages 63 through 64 of the guide gets into better detail of the definition of standard. In my opinion, the term used by manufacturers is causing some confusion because they talk about premium, advanced, standard, basic, right? One tends to think the allowed amount is supposed to cover the cost of the manufacturer's standard technology, when in fact, it barely covers the cost of entry-level technology in most cases. Some it does. What's happening is it's leaving practices to write off a substantial amount or worse, engage in fraudulent billing practices. Now, unfortunately, I'm providing an oversimplification of upgrading just to help you see the complexity involved here. When done correctly, you can be legally compliant and reduce your practice's financial burden. If you feel like I'm speaking to your practice's issues, please get the guide and review this. And if it doesn't make sense, we have an email, reach out and ask for clarification or help. Many of us are billing carriers with whom we are not in a network contract. And again, there's a lot more to out-of-network adjudication but I wanted to bring this up just to illustrate that the patient is responsible for 100% of what insurance doesn't pay. Now, there are states with very restrictive balance billing laws so we have to pay attention to those as well. And balance billing, I don't get into today. That is outlined in the guide. But the organization isn't contracted to accept the terms of a contract agreement, right? So it doesn't mean we don't have to comply with state and federal laws. It just means that we don't have to accept their contracted rates. Does it mean that being out-of-network is the only way to get paid in full? No. Remember those dangerous repricers we discussed a few moments ago? This is where they come in. Carriers use repricers to negotiate with out-of-network providers to reduce their costs. What they do is they send you a fax or a letter asking you to accept a reduced rate. And in exchange for that, they'll pay you faster. Now, that's malarkey sometimes because I've had it where, hey, if you sign this agreement, we'll pay you in five to seven business days. That does not always happen. There are many dangers to repricers. So if you don't understand how they work, please refer to this section of the guide and read it thoroughly. While collecting charges in full may seem like the best reason to stay out-of-network, there's some disadvantage of this. Prospective patients will often refer to their list of network providers and only seek care from those on that list. The guide doesn't list what makes a contract good or bad, nor does it inform you if you should be in or out of network with any specific carrier. Instead, what our team has done here is outlined scenarios to assist you in making appropriate decisions that align with your individual goals or needs of the practice. Now, some of us can relate to this poor guy. Sometimes it just plain feels like insurance is trying to shake every penny possible from us. Unfortunately, sometimes the issue is us. We leap into contracts, signing them that are just really genuinely bad for business. Remember, it's okay to say no and remain out-of-network. You need to remember that contractual obligations are applied to billed charges when those charges exceed an agreed-upon contracted rate. If the rate is baloney, then don't accept it. Now, of course, this guide offers more insight on this, but I bring it up because I think the failure to truly understand the contract is why we're continuously having so many of our friends suffering from poor reimbursement. And another thing, contractual obligations can't be applied when you don't have a contract. You know, those adjudications that come, you have no contract, and then they have this CO-45 saying that you have to write this amount off. If you aren't in-network, have them fix that. It was an error and they need to change it. That's really important with the No Surprises Act and if you're in a state with balance billing laws, comprehensive balance billing laws. Here's another frustration. When you don't fully understand how benefits are paid out and then you try to counsel your patients on what you expect insurance to pay and what you expect their out-of-pocket expenses gonna be, that can go wrong real quick. And if you've been bitten enough, you've realized that 100% doesn't mean 100% of what you billed, right? But there are still substantial mistakes made and the failure to understand the distribution of funds here is what really bites. Let's look at this example. Basic math would tell us that they're gonna pay 80% of $2,000. If your patient purchased $4,000 hearing aids, they have a $2,000 deductible. It leaves $2,000 remaining. So 80% of that is $1,600, right? That's simple math. Hopefully you're all following that. Obviously, you know I'm gonna tell you that this is incorrect or I wouldn't be bringing it up here, would I? You see the majority of people forget about that gosh darn allowed amount. Now, if you were one of those providers who misinformed your patient on the expected insurance benefit, you're going to get yourself in trouble. It is the patient's responsibility ultimately to understand their benefits plan. So if you're going to extend a courtesy to them by checking their benefits, you should hire a person who can be well-versed in the subject or be well-versed yourself. Have any of you figured out what the insurance payment would be based on this information? It's $400. The carrier's paying off their allowed amount. That's the budget they set for the code that you billed under. That remains, they're responsible for 80% of $500. And if you don't see how this math just worked out, they allow 2,500. You have to take the deductible off of that first. So we have $500 is the financial responsibility of the insurance carrier, and then they pay 80% of that portion. That's where 400 comes in. And when you've advised your patient that they're going to pay $1,600, and then it turns out that paid 10% of the total billed charge, both you and your patient are gonna be angry. When claims are submitted, they're done typically by placing the word signature on file which replaces the actual signature on a claim, right? I've noticed that many providers are not collecting these signatures. Appendix B is dedicated to the necessary financial documents and includes four separate documents that may need to be utilized to protect your practice when you bill a health plan. So that's a big deal. If you don't know what I'm talking about, that'll be your friend. One of the most challenging things for small practices is determining how to price your products and services. This is covered in chapter five. Very confusing for a lot of people, a charge master. I haven't met a person who's using a charge master, unfortunately, yet either, but you all need to have it. That's a list of charges for items and services that are available within the walls of your practice. It should be reviewed and updated at least annually, and it does not include supplies you use during the course of treatment. Now, super bills, on the other hand, which a lot of people are using, that's a quick method of marking the items and services provided during a visit with your patient and should not include prices. A fee schedule is not used by a practice. It's used by a carrier and it's sent to the practice to outline what they allow or pay on covered items and services. Nearly 10% of the guide is dedicated to helping you clearly understand this, so you can not only comply with the laws, but you can generate a profit. Here's how I personally set mine up. In Excel, I create a spreadsheet with each category of items, services, and fees. Those are rolled into the charge master. Now, you might be thinking, because I hear this a lot, it doesn't apply to me. I'm a bundled practice, Samantha. I would argue it applies to you even more then, because you're less likely to substantiate your claim that your fees for hearing aids are reasonable. Please remember, usual, customary, reasonable is the requirement. Simply arguing that your patient is receiving free services for life does little to show what the actual value is. So if you are operating a bundled pricing model, you would also want to have a system or need to have a system that shows what services you're providing, how often they're provided, as well as the value of those services. Please note that while I do have a tab for professional supplies here, that includes impression material, speculas, and those things, that's not on the charge master. We keep track of those costs because then they support what I'm charging for the service, right? I've got hard costs into impression material, so it supports the cost for my charge for an impression. Again, it's okay if you're bundled, you just need to have all of your costs outlined so it supports what you're charging on your hearing aids. Although a super bill does list items and services, simply marking a box on a super bill is not enough. If you are audited and you feel that this super bill will offer at least some protection, you may quickly find yourself paying back a substantial portion, if not all, of what you've been paid by the carrier, and they won't limit that to the single claim. Please remember that super bills do not replace clinical documentation. Whether you're bundled or not, if you render a service, when you render a service, I should say, you need clinical documentation that the service you provided was written out, it was necessary, you have to put why the patient come in, came in, what you observed, the actions you took, recommendations you've made, the follow-up plan, and most importantly, and most often forgotten is that the patient understood and agreed with it. Some practices neglect this because the service was provided for free. However, fitting and follow-up care is often bundled into the cost, and so you need to support it. For example, if a patient walks in my office with a broken receiver wires, I have to write out why I'm changing it, it's all necessary. Using a standard super bill, like the one in the guide, it's on the left side of your screen, you can use it as a template to develop your own, the right side of the screen is the one I have in my practice. What you do is you simply just say, I've got these services and you write them out, and then you use it as a check mark because I can never finish all my notes in an appointment, I check off the boxes, and then I use that to make my notes. It's just not possible for me to do it all another way. Don't forget, you need the notes. Here's a misconception. The name of your service does not need to match the CPT or HCPCS definition. You call it what it is in your practice, and then you have a protocol establishing what those services include. Just make sure your documentation supports the use of the code. An example, in my practice, we call hearing aid checks routine maintenance, but the service we perform may be varied on the individual needs of the patient. If I only change an earbud and a receiver filter, I can't put that under the 92553 code and say that I did all of the things the service included or the code included. I have to append it with a modifier. So personally, I set my super bill up so that I can mark the proper one so my staff doesn't inadvertently bill. All right. I often see posts on professional Facebook pages asking coding and billing questions. There are so many instances where people are advising others of not only incorrect details, they're sometimes filled with illegal advice. Please be careful when taking advice from people who have no authority in billing, coding, or compliance. IHS and the managed care team has created this guide as a resource for you to answer those questions. If you need further assistance, please reach out and let us help you. The guide is gonna go through a lot of misconceptions that back our facts up. And here's one important one. You can bill level one CPT codes. I hear this all the time. I get a lot of flack for saying dispensers can bill this. But if you read the text here, it clearly states that it doesn't have to be a physician that builds the code unless the code requires medical decision-making, which is out of our scope of practice, right? So you do have to operate within your scope of practice, certainly. There are some large companies and heavy hitters, if you will, who will tell you that dispensers can't bill 92557, but that's not true. This is just one example. Chapter seven is filled with fact-based advice on misconceptions, including references. Clearly, I couldn't cover everything included in this 150-page resource. The bits I selected today were to show you what you will hear people, what people complain about, or what people are having problems with. That's what I pulled out. But you really need the guide if I spoke to anything that you're concerned with. So here's how you're gonna access it. IHS is going to get you information on how to reserve a copy. Personally, I do digital and print because I like to highlight everything. And certainly I like the electronic control find and search that way. But your membership is really gonna pay off here. So if you're not a member, it would be worth joining IHS to get the guide. I mentioned the compliance plan throughout this presentation. I've heard of people getting it and never using it. I cannot stress enough the importance of having a compliance plan in place. The managed care guide serves to help practices understand the rules. The compliance plan development guide is a tool that helps you steer in the right direction once you're participating. Go to IHS info, sign in, and go down to resources because you do have to be a member to get this guide. If you haven't already received the information, I believe you'll be getting those in an email soon. So be on the lookout for that from IHS. Now, if you have any questions about the material I presented today, or perhaps you need more information, now's the time to ask them. Thank you, Samantha. Let's go ahead and take some questions. As a reminder to our attendees, please enter your questions into the Q&A box at the bottom of your screen. We'll go ahead and take as many as we can in the time remaining. Our first question is from Dan. You said that dispensers can participate. However, I've been denied network participation because I am a dispenser. Is there something I have to do to become qualified as a dispenser to participate? Well, participating is really important to know. The term participation doesn't mean the same as being in a network. So if you are billing an insurance company, you're participating. Being in network, I have heard of some networks saying you have to be an audiologist to get into our network. The guide offers really important information on discrimination. So downloading that will actually give you the best information here, but you don't have to do anything special. Okay, great. All right, another question from Carol. I missed the part on balance billing. Is it legal? You didn't miss it, Carol. I didn't get into the depths of balance billing because that varies by state. And so that information needed to stay in the guide. Balance billing is illegal in some instances. And so some states offer very comprehensive protections against it. So we need to be careful and we need to know particularly what state a person is in to even come close to advising on that. It also depends on your network status. If you're in network, you can't balance bill unless you've used the appropriate S codes to upgrade and you were allowed to do it. Great. All right, a question from Phelan. Does insurance cover maintenance on hearing aids? Hey, that's a great question. Many of them do. Some of them don't because they also bundle much like some surgeries. They have a code that they say it bundles every aspect of the surgery. They do that for hearing aids as well. So you do have to know. Do that in your benefits and eligibility check, which is in the appendix. It guides you to make sure you're asking all of the appropriate questions. Sometimes we just ask if hearing aids are covered, but in the guide in the very back, I can't remember what page it's on right now. It's up there though. It tells you what codes to be asking for and then you can determine if that is a separate billable item. All right, great. Another question from Amber. For a larger hospital system, how do we set up compliance with Medicare for a new hearing aid dispenser? That's a great question. It's quite loaded. In this case, I will say probably because the number of people on here might be small for that circumstance. I'd like to handle that offline. Reach out to IHS so that we can help you deal with that specifically because there are going to be a variety of specific things you'd have to set up and address. Sure. All right, a question from Asher. When I try to bill, they tell me it has to go to Medicare first and it's being denied. So I asked the agent, what address should I send it to? And they say, they don't know. Are you able to help? Yeah, they're not gonna know. So as dispensers, we can't bill Medicare directly. And so we go back to that, one of those early slides I was talking about where I said, you need those Medicare denials. The reason they need you to bill them is to show that Medicare isn't going to pay on it. So instead what you can do is use one of the two resources or letters that we're giving you to send to them. Sure. That'll be worth your money to get the guide for sure. Absolutely. All right, and we have a question from an anonymous attendee. What resources can be provided for updates on the HIPAA regulations? Okay, so I wanna make sure I understand that question because we have to attend annual HIPAA training, right? And so there are a lot of resources when it comes to HIPAA. So I'm wondering if the question applies to us specifically as dispensers because we talk about it as HIPAA but we've got HIPAA, the privacy, high-tech, privacy, security of electronic records and then you have breach notification. So there's a lot to unpack. The guide spells out quite a bit about HIPAA and where you'd go for some of your training but the internet of things, there's so much on there that we don't want you to get outdated information. So looking through the guide to see currently the best resources for you to go to. And then one of the commitments for Managed Care and Compliance Committee is to make sure we're feeding you that information that is applicable to both dispensers and audiologists. Great. All right, another question from Deborah. Can associate IHS members get the guide and how exactly do I get it? Hey, good question. I like associate members. Of course, you're a member of IHS, you're a member of IHS and you're gonna be getting information from the association here very soon telling you how to get that. But what we're doing right now is having people reserve their guide. So you'll have my understanding, I'm not employed with IHS. And so it's my understanding that you'll get information on how to reserve it so that as soon as it's printed or released, you'll get a copy of it. Is that maybe true, Sean? I believe that's true. Yes, you are correct. That is the process for how it will go. So there'll be a follow-up email that will be sent out with a link to sign up for the reservation list and then it'll be distributed once we have everything finalized here and then very shortly. All right, another question from Lisa. Is there training for office managers that we can have somebody enroll in? Hey, love it. So I have been trying to get one specifically for staff because I feel like that's where really the money is, not for us, but for you as members, as you for participants. I'm not speaking this year at IHS on insurance because I really want us to be speaking to the people who day in, day out are doing the billing and we need to understand how to code claims properly. So be on the lookout. As soon as we can put the pieces of that together, I do wanna offer an office staff training separately. It's coming. All right, and a follow-up question from Asher. I'm still not clear of what I need to do when I get a rejection, telling me that it has to go to Medicare first. Right, it can't go to Medicare first if you are a dispenser. So I'm gonna bet Asher's a dispenser. You cannot bill Medicare directly. And so there are things that you can do. And one of those things is not bill Medicare. It's to send a letter to the plan that you're trying to get the reimbursement from. And that letter, there's a couple of them, in the guide that you will copy and send out. You're not going to bill Medicare directly. Sure. Okay, great. Well, oh, we have one more question. I think we have time for one more from Ethan. Is there any billing services that are good at following these guidelines? All billing services should be filling, following all these guidelines. I don't know of all the billing services out there. I have a company who offers it clearly, and I'm a compliance officer for that company to make sure that we're following it. So I wish I could answer that question, but I don't know every single one of them, unfortunately. So I couldn't put a stamp of approval on them, and I probably wouldn't wanna do that anyway. Just make sure. What's really important is, so the OIG offers a list or says, this is what your company should be doing, and that's actually in the guide. It tells you what to be on the lookout for. And even if you have them doing those things, you know you're still legally required to have your own compliance plan to keep them and hold them accountable for theirs. So I'd say to be interviewing them and making sure that they are doing those things as well. Well, that's great. Well, I think that's all the time we have for Q&A today. Thank you to Samantha Sikorsky for your partnership and sharing this valuable presentation, Unveiled Managed Care Guide. To get in touch with our presenter, you may email them using their email addresses on screen. And as a reminder, for information on receiving a CE credit for this webinar, please visit the IHS website at www.ihsinfo.org slash webinars. 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. Thank you again for joining us today. We'll catch you at the next IHS webinar.

IHS webinar

Unveiled Managed Care Guide

participating in managed care

contracts

coding and billing

HIPAA regulations

communication with patients

insurance benefits

out-of-network participation