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FAQs Regarding the Academy’s Position on the Audiology Patient Choice Act

FAQs Regarding the Academy’s Position on the Audiology Patient Choice Act

Which aspects of the bill does the Academy support?

Why has the Academy not endorsed the legislation this Congress?

Why does the Academy support streamlined, or direct, access to audiologists as a legislative priority?

What is the position of members of Congress, the medical community, and other audiology organizations regarding this legislation?

Why is the Academy concerned that this legislation does not include an "opt-out" and what does that mean?

What is the impact of the bill on patient choice and access to audiology services?

Will the bill result in higher pay for audiologists?

Will the bill subject audiologists to new requirements in their practice?

Would passage of the bill guarantee audiologists the ability to access to E&M codes?

Will passage of this bill alter which services are covered for Medicare beneficiaries?

Does the designation of limited license physician status automatically apply to all audiology services?

Will passage of this bill guarantee an increase in salary and/or professional respect for audiologists?

Might the bill have the unintended consequence of reducing reimbursement levels for audiology services?

Will audiologists have to see all Medicare beneficiaries?

Might supporting this bill have a negative impact on key relationships that have the potential to move the profession forward in the future?

Why does the current legislation not reflect a risk worth taking?

Why did the Academy previously endorse the legislation but has now opted not to support?

What legislation would the Academy be interested in supporting at this time?

What is the Academy doing to advance their goals of improving access to audiology services and getting reimbursed for performing our full scope of practice under the Medicare program and across private payers?

What can I do in my practice to better position audiology for long-term advancement in the legislative and regulatory environment?

Which aspects of the bill does the Academy support?

  • The Academy endorses the ability of Medicare beneficiaries to directly access the services of an audiologist without the requirement of a physician referral.  Most individuals with private or federal government insurance already have this ability.  Medical necessity would still be a requirement for reimbursement.
  • The Academy supports legislation that seeks opportunities for audiologists to be paid for services within their scope of practice and commensurate with their level of education. This legislation does not seek to make changes to an audiologist's scope of practice.

Why has the Academy not endorsed the legislation this Congress?

The Academy cannot endorse the attainment of LLP status at this time without the following assurances and considerations: (1) the ability for audiologists to opt-out of the Medicare program if their practice model so dictates, (2) access to the full scope of provider benefits including the ability to bill and be reimbursed for evaluation and management (E/M) services, not just technical services. Additionally, if enacted, this legislation would result in significant regulatory changes as the Medicare audiology benefit would need to be redefined per the law. The Academy believes that we must work with entities like CMS and other organizations to ensure the Medicare benefit is rewritten in a way that is favorable to audiology.

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Why does the Academy support streamlined, or direct, access to audiologists as a legislative priority?

The Academy endorses the ability of Medicare beneficiaries to directly access the services of an audiologist without the requirement of a physician referral.  Most individuals with private or federal government insurance already have this ability.  In addition to decreasing costs for beneficiaries and the Medicare program, direct access is in line with recommendations by the National Academies of Sciences, Engineering, and Medicine (NASEM) to improve access to high quality hearing health care while improving the affordability of hearing health care. Additionally, with the pending legislation dictating the development of a new class of over-the-counter (OTC) hearing aids, which consumers will be able to access without a prescription, NASEM recommended the U.S. Food and Drug Administration (FDA) should remove the regulation that an adult seeking hearing aids be required to first have a medical evaluation or sign a waiver of that evaluation.  This change begs the question if a physician referral should be warranted for a patient to have their hearing tested when they don't need a referral to ultimately use a hearing device.  The Academy strongly supports the ability of the patient to have straightforward, cost-effective access to high quality care from audiologists, who are the providers of choice for patients managing a hearing or balance concern.

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What is the position of members of Congress, the medical community, and other audiology organizations regarding this legislation?

Currently, this legislation is endorsed by the Academy of Doctors of Audiology (ADA) and the Hearing Loss Association of America (HLAA), as well as some other state and local organizations.  The American Speech-Language-Hearing Association (ASHA) has remained neutral on the legislation, favoring their own legislative effort, the Medicare Audiology Services Enhancement Act, which aims to achieve comprehensive audiology benefits. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) has directly opposed the Audiology Patient Choice Act, and specifically the attempt to achieve limited license physician status for audiologists. In addition to the AAO-HNS, more than 30 other medical societies, 44 state medical associations, and 57 state specialty associations have co-signed the letter of opposition. This opposition, combined with the current legislative and regulatory environment, make successful passage of this bill highly unlikely.  Furthermore, discussions between Academy representatives and key House/Senate members have suggested this bill is not a priority as the current Congress comes to a close.

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Why is the Academy concerned that this legislation does not include an "opt-out" and what does that mean?

Currently, doctors of dental surgery (DDS) or dental medicine (DMD), doctors of medicine (MD) and doctors of osteopathy (DO), and doctors of optometry (OD) may opt-out of Medicare and privately contract with beneficiaries for the purpose of furnishing items or services that would otherwise be covered (Medicare Physician Guide, p21). Additionally, certain practitioners are also afforded this option. It is important to note chiropractors are not afforded the ability to opt-out of the program, even though they have limited license physician status in the program.  As a result, these providers must accept Medicare reimbursement rates for any services determined by Medicare to be a covered benefit. The current bill does not specifically provide audiologists the ability to opt-out and many details of the regulatory changes that would occur subsequent to passage of the bill would not be determined until later.  The Academy believes it is important that the ability to opt-out be clearly defined in the proposed legislation before endorsement is possible.

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What is the impact of the bill on patient choice and access to audiology services?

The positive aspect of this bill is that it has the potential to improve access to audiologists for Medicare beneficiaries.  However, those benefits could also be realized by improving access to audiology services and expanding coverage of audiology and vestibular services without the LLP component. We believe an incremental approach would be more feasible in this political environment and also would allow the Academy to collaborate with stakeholders like CMS to position audiologists to achieve future goals relative to status under the Medicare program.

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Will the bill result in higher pay for audiologists?

There is no guarantee that this legislation would result in higher pay for audiologists. Audiologists may currently bill patients directly for services that are not covered by Medicare. If enacted, this legislation would require audiologists to accept Medicare rates for services that they may have previously billed the patient for at their customary and reasonable rate. As written, this legislation would require the Medicare audiology benefit to be redefined through the regulatory process. While the bill specifically mandates that audiologists be given LLP status, it is silent on the exact regulatory changes that would be recommended or implemented.  These changes could be extensive and complex and leave little certainty as to the impact of LLP status on the practice of audiology. As such, it is difficult to define specific outcomes, such as allowing access to E/M services.  There are many variables that will determine payment rates for audiologists, making it difficult to ensure higher pay for audiologists.

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Will the bill subject audiologists to new requirements in their practice?

Yes, audiologists will be subject to new requirements in their practice. We recognize that certain changes, specifically with regard to participation in the Quality Payment Program, will be forthcoming regardless of achieving LLP status, and the Academy has been active in both educating members and engaging with CMS to position audiologists to successfully adopt this new program. With LLP status, there may be more stringent reporting requirements than may/will be currently required for audiologists. We want to maximize opportunities for audiologists to successfully adopt new reporting requirements prior to facing the same requirements as physicians who have been participating in the program since 2017.   

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Would passage of the bill guarantee audiologists the ability to access to E&M codes?

While passage of the bill, including LLP status, might open doors for audiologists to utilize E/M codes, it is not a guarantee, and coverage of those codes would be determined on a state by state basis.  Ultimately, coverage would be determined by CMS once the audiology benefit is rewritten.  In other words, while passage of the bill would regulate the application of limited license status, the specifics of how it would be applied for audiologists would be determined by CMS. 

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Will passage of this bill alter which services are covered for Medicare beneficiaries?

Passage of the existing bill will not guarantee comprehensive coverage of audiology services.  As is the case now, only those services that are medically necessary would be covered by Medicare.  However, if this bill were to pass, the entire responsibility for determining and documenting medical necessity would fall to the audiologist. The Academy recognizes that audiologists are currently required to determine medical necessity before providing diagnostic tests and that members continue to contact the Academy with  questions about determining medical necessity and other requirements for billing Medicare. The Academy continues to work with other audiology organizations to educate members on such topics and ensure compliance with current Medicare requirements.  It is important to note that if the services provided are related to dispensing or programming hearing aids, the services would continue to be statutorily excluded. 

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Does the designation of limited license physician status automatically apply to all audiology services?

As we have seen with chiropractors, physician status could result in a Medicare benefit being limited to one service.  Coverage for chiropractic services extends only to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by X-ray, provided such treatment is legal in the State where performed (Medicare General Information, Eligibility, and Entitlement, Chapter 5, page 34).We cannot currently assume that application of this status would apply to all services.  The downside for members is that they would be subject to all requirements imposed on physicians regarding documentation while the benefit may be limited to a single provided service.

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Will passage of this bill guarantee an increase in salary and/or professional respect for audiologists?

Audiologists are already doctoral level health care providers, who are recognized as doctors by colleagues, peers, state licensure boards, members of the community, and patients. Medicare is a federal health insurance program that defines coverage for services for beneficiaries, but does not define professional scope of practice. There is also no guarantee that this legislation would result in an increase in salary for audiologists, and in fact, passage of this bill could result in lower reimbursement to audiologists for their services, as audiologists are required to accept Medicare rates for services previously billed directly to the patient. This would depend on Medicare payment rates, the final definition of covered services per the Medicare audiology benefit, and other factors such as the ability for audiologists to access E/M services and to opt-out of the Medicare program.  Additionally, CMS closely monitors utilization of services and has screens in place to identify services that exceed a certain utilization threshold. If utilization/billing increases for certain services, it is possible that CMS may request a review or resurveying of these codes by the AMA RUC and related specialties. In most cases, valuation for such codes tends to decrease after review. This is not specific to audiology, but has been seen across all specialties.  

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Might the bill have the unintended consequence of reducing reimbursement levels for audiology services?

Currently, audiologists can bill patients for non-covered services. For any services covered by CMS following passage of this bill, presumably those that are medically necessary and currently have CPT codes, audiologists would have to accept reimbursement rates set by CMS.  For example, while services such as cerumen removal, vestibular rehabilitation, and aural rehabilitation are not currently covered benefits when provided by an audiologist, audiologists can bill patients directly for these services at a customary and reasonable rate determined by the audiologist.  If these services were determined to be reimbursable by Medicare after passage of this bill, audiologists would be required to participate in Medicare and accept whatever reimbursement is deemed appropriate by Medicare.  The Academy recognizes that this is a challenge that will need to be considered with any legislation that increases Medicare coverage of audiology services. However, the Academy believes that there may be opportunities to minimize this impact with strategic consideration of the manner in which comprehensive coverage is achieved. 

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Will audiologists have to see all Medicare beneficiaries?

This will depend. Currently there is no specific provision in this legislation to allow audiologists to "opt- out" of the Medicare program. Opt-out is a contract between a provider, beneficiary and Medicare where the provider or beneficiary does not file a claim to Medicare. The physician or practitioner bills the beneficiary directly and is not required to follow the fee-for-service charges determined by Medicare. Audiologists are currently not included on the list of providers who are allowed to opt-out of Medicare. If a patient requests that a claim be filed to Medicare for a covered service, the mandatory claims statute requires that the claim be filed.

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Might supporting this bill have a negative impact on key relationships that have the potential to move the profession forward in the future?

The Academy has spent considerable time and effort to work with audiology, physician, payer, and government stakeholders across all fronts. Relationship-building has been a key priority in the past few years from our involvement with the FDA relative to OTC hearing aids and our efforts to serve as a ready resource with the Agency. The Academy works with audiology and physician groups in the context of the AMA CPT Editorial Panel and RUC and has established collaborative relationships with many specialty organizations whose support will be essential in advancing our own legislative and regulatory agenda. We continue to communicate with CMS on important policy matters relative to payment, quality reporting, communication, etc. and want to ensure we are having the right conversations with CMS with regard to making policy changes and the best way to accomplish this goal. We also continue to work with physician groups like AAO-HNS and others on other legislative and regulatory matters to work towards common goals in the health care arena.

The Academy has built these relationships to lay the groundwork to advance the goals that have previously challenged us, namely direct access and expanding coverage for audiology services. We believe an incremental approach that engages, rather than alienates these stakeholders is the most productive path forward. We also believe that sometimes the approach can be equally important as the policy itself.

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Why does the current legislation not reflect a risk worth taking?

  • Discussions with congressional leaders indicate that this bill is not a legislative priority in this congress. The Academy leadership felt that it would be disingenuous to sign on to a bill and not provide further advocacy; however, expending resources for further advocacy would not yield different results. 
    • Bloomberg prospectus and intel from congressional meetings suggest few, if any, vehicles remaining to pass health care legislation.
    • This legislation will require considerable resources and political capital to advance this legislation
    • Congressional staff recommends narrowing the focus of the legislation to improve feasibility of passage.
    • This bill has only 26 co-sponsors on the House side and 1 co-sponsor on the Senate side.
  • An expansive legislative approach is open to greater opposition by physician groups.  Physician groups have already indicated to the Academy an intention to oppose the Audiology Patient Choice Act specifically. If the Academy signs on to the bill, we are confident that the opposition will become more visible and pronounced.  The Academy recognizes vulnerabilities for the profession, such as variability of educational programs, that will likely be targets by the physician community, as evidenced by the AMA Scope of Practice Series and their various approaches in opposing expansive legislation for other health care disciplines.  We believe that the profession needs to be prepared in common messaging to address those vulnerabilities.  As well, we believe that we are more likely to achieve legislative success through eliciting support from a broader stakeholder community than only the audiologists.   A political reality is that there are 68 actively licensed physicians for every audiologist in the United States
  • Along with the LLP designation comes expectations similar to those for physicians.  The Academy wants to ensure that it's members are fully prepared to adopt this status and realize the associated responsibilities. Some examples of those responsibilities include:
    • Audiologists will bear sole responsibility in demonstrating medical necessity for covered services
    • Audiologists could be expected to fully-participate in CMS' new Quality Payment Program, including increased requirements for utilization of electronic health records and more stringent reporting requirements than may be currently required for audiologists. The Academy fully recognizes that participation in the QPP will be a reality for audiologists as early as 2019. The Academy has met with and continues to communicate with CMS on inclusion of audiologists in this new payment system and how best to position and prepare our members for this new program, including opportunities to incentivize audiologists for adoption of EHR technology. We recognize that there are changes on the horizon for audiologists and we want to ensure members are prepared by providing educational resources and advocacy before CMS. The Academy wants to ensure we are meeting increased reporting requirements with the appropriate level of support to our members from both the organization and CMS. 

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Why did the Academy previously endorse the legislation but has now opted not to support?

Since 2014, the Academy has been in discussion with ADA and ASHA regarding the content of this bill.  The Academy did agree to support the bill when ADA introduced it in a previous congress, and the bill was not successful.  When ADA mentioned reintroducing the bill for the 115th Congress, the Academy requested reconsideration of the bill language.  In January 2017, the Academy submitted a series of questions to ADA; responses to these questions were received from ADA in July 2017, two months after they introduced the bill in May 2017.  By this time, the Academy had conducted extensive outreach to congressional offices regarding this legislation, including the committees with jurisdiction over the legislation. The opinion of the Board and Academy representatives following this investigative process concluded that the legislation, as currently written, is too broad and far-reaching to be successful in the current political climate.  As such, the Academy did not provide an endorsement of the legislation, rather we agreed not to actively oppose. It is important to recognize that decisions regarding legislation are not binary (support/oppose).  Rather, the Academy continues to evaluate and assess opportunities to collaborate and to further our agenda. Refer to the  Academy's timeline of events for more information.

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What legislation would the Academy be interested in supporting at this time?

The Academy strongly supports streamlining access to audiology services and being recognized and reimbursed for performing our full scope of practice under the Medicare program and across private payers. We view these two goals as critical in supporting the autonomous practice of audiologists. Advancing these two goals reflects an incremental approach that we feel is more politically feasible at this time given the current climate on Capitol Hill, communications with congressional staff, and discussions with other stakeholders, including other audiology professional organizations and hearing health care specialty societies.  The Academy is working to identify a legislative approach that will meet these two goals and represent a sound legislative strategy based on the feedback we have received from Capitol Hill.

Furthermore, the Academy is interested in cultivating new and ongoing collaborative relationships with other professional stakeholders, consumers, and legislative resources to identify incremental legislation that furthers our ultimate objectives of improving the practice of audiology for members without causing undue compromise or sacrifice by our members.

The Academy remains active before federal agencies and on Capitol Hill advancing a number of other legislative and regulatory initiatives. To learn more about these initiatives, visit:

The Academy is interested in supporting legislation that allows us to advance the profession of audiology while improving access to hearing healthcare but seeks an opportunity that allows us to do so on our terms and allows us to set the tone as regulatory changes are implemented.

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The Academy has indicated that improving access to audiology care and getting reimbursed for performing our full scope of practice under the Medicare program and across private payers are the two primary goals for the Academy.  What is the Academy doing to advance this goal and increase payment and access for audiology services?

  • The Academy has long advocated for improved payment for audiologists across private payers, most recently convening a payer summit in October to foster relationships with private payers and express audiologists concerns over issues like not being able to bill payers for E/M services.
  • Since the start of the Quality Payment Program (QPP), the new CMS quality payment system, the Academy has met with and continues to communicate with CMS on inclusion of audiologists in this new payment system and how best to position and prepare our members for this new program, including opportunities to incentivize audiologists for adoption of EHR technology. We recognize that there are changes on the horizon for audiologists and we want to ensure members are prepared by providing educational resources and advocacy before CMS.
  • Academy representatives have long advocated that audiologists be awarded an independent seat on the American Medical Association's (AMA) Resource Value Scale Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC). Previously, both audiology and speech-language pathology did not hold separate "seats" and were dually represented by ASHA. The RUC process results in recommendations made to CMS regarding reimbursement rates for codes under the Medicare Physician Fee Schedule. The Academy views representation on this body as critically important for audiology to have an independent voice with regard to Medicare payment. No other audiology organization supported this effort at the time.
  • Through the AMA RUC and CPT Editorial Panel, the Academy is working with other audiology and physician stakeholders to improve coding and valuation for audiology services by revising the audiology code set.
  • Academy leaders and lobbyists have met directly with Republican and Democratic leadership to discuss options and opportunities for improving access to care.
  • The Academy submitted comments to the House Ways and Means Committee, Health Subcommittee in August to respond to their response to their request to reduce red tape within the Medicare program and has continued that outreach by meeting regularly with both House and Senate offices. These comments addressed access issues within the Medicare program and the need for audiologists to be able to bill E/M services.
  • The Academy will be meeting with CMS to discuss regulatory opportunities to achieve direct access and explore options for expanding coverage for audiology services under the Medicare program. The Academy will also discuss LLP status to better understand the implications for our members.
  • The Academy has commented extensively to CMS on payment matters including the Medicare Physician Fee Schedule, the Quality Payment Program, the Hospital Outpatient Prospective Payment System, and the CMS Innovation RFI for improving innovation and care models within the Medicare program. The Academy works with other stakeholders like ASHA, physician groups, manufacturers, and the AMA RUC on such comments to advance the profession.

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What can I do in my practice to better position audiology for long-term advancement in the legislative and regulatory environment?

  • Unbundle your services to increase transparency so that patients understand the value of audiologist services as separate from hearing devices
  • Don't give services away for free
  • Be vigilant in appropriate identification and documentation of medical necessity and appropriate billing practices
  • Educate your patients about audiology and the current political and regulatory red tape that prevents them from accessing audiologists easily and affordably
  • Educate referral sources (particularly primary care and ENT physicians) regarding how direct access can improve care for patients and optimize their ability to accommodate challenging medical or surgical cases in their practices, as opposed to straightforward hearing loss that audiologists can easily manage
  • Educate your state and federal legislators on the benefits of direct access for patients and the challenges that audiologists face in terms of appropriate reimbursement for services

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