For the public at large, Medicare evokes the concept of a health insurance plan for the aged or retired population. Created in 1965 to provide a safety net for older individuals who faced substantial medical problems, the benefits available to Medicare beneficiaries are generally more limited than those available through private health insurance plans. Medicare has four parts (Medicare.com, 2018) as summarized in Table 1.
In 2017, there were approximately 58 million persons enrolled in Medicare, of which about 50 million were age 65 or older and 9 million were disabled (CMS.gov, 2019). Enrollment in Traditional Medicare was about 39 million (67 percent), while enrollment in Medicare Advantage programs was about 20 million (Kaiser Foundation, 2018a). Over the next 30 years, the number of Medicare beneficiaries is expected to increase to 92 million people (Kaiser Foundation, 2018b).
The Economics of Medicare and Hearing Care
CMS accumulates and tracks data about services provided to Medicare beneficiaries by health-care providers, including audiologists. In the context of economic data, Medicare tracks data such as the number of times a current procedural terminology (CPT) code, which is developed and owned by the American Medical Association (AMA), is billed (utilization) by an individual provider, the total allowed charges for each submitted code, and the total payments to the audiologist for procedures. In addition, CMS tracks the co-morbidities associated with each beneficiary receiving services from an audiologist, the number of beneficiaries served, the number of different (CPT) codes submitted, and the total numbers of procedures billed. As might be expected, CMS also collects data on the beneficiaries, and relates this data to the services provided by audiologists.
Medicare Beneficiaries Served by Audiologists
Determining the exact number of Medicare beneficiaries served by audiologists is confounded by several variables. First, many procedures are billed under the names of physicians, practices, or hospitals. For example, in 2017, the following specialties and providers submitted charges and were paid for comprehensive audiometry: audiology, otolaryngology, nurse practitioners, internal medicine specialists, allergists, and family medicine physicians. Audiologists may have performed these procedures, but their names or national provider identifier (NPI) numbers do not appear on the submitted bill.
Second, there are those services provided to Medicare beneficiaries but are denied payment due to reasons such as lack of medical necessity, not having a physician referral, not a covered benefit, etc. The number of patients where charges were submitted for audiologic services, but payment was denied, cannot be ascertained.
Finally, there are Medicare beneficiaries who may be evaluated by an audiologist who does not bill Medicare because their services are associated with amplification devices that are not covered by Medicare.
For the purposes of this article, the total number of referrals to audiology, exclusive of referrals for vestibular tests, is based on the sum of the number of patients receiving air conduction (CPT* 92552), air and bone conduction (CPT 92553), and comprehensive audiometry (CPT 92557). Therefore, every referral must receive a minimum of air-conduction testing and will get one of these three codes, but no referral gets more than one of these three codes at any one visit. Using this assumption, the total number of referrals to audiology in 2017 was 1,331,888 (Table 2).
As shown in Table 2, the number of persons enrolled in traditional Medicare and the number of referrals to audiology have increased steadily over the same time. The percentage of Medicare beneficiaries referred for audiologic testing has remained fairly steady at about 3.4 percent over the past 10 years, which is disappointing considering physician marketing efforts and Medicare's "Welcome to Medicare" Preventative Office Visit Program.
|YEAR||TRADITIONAL MEDICARE ENROLLMENT||REFERRALS TO AUDIOLOGY||% REFERRALS TO AUDIOLOGY|
Audiologic and Vestibular Billing and Payments Across Professions
In 2017, Traditional Medicare paid nearly $82 million for audiologic diagnostic tests (CMS.gov, 2018b) to audiologists and any other provider who might use these codes. Diagnostic tests include typical hearing assessment procedures (e.g., air conduction, bone conduction, speech measures, immittance, otoacoustic emissions, etc.), historical tests (e.g., Bekesy, tone decay, short increment sensitivity index [SISI], etc.), and specialized assessments (e.g., auditory brainstem response [ABR], electrocochleography [ECoG], tinnitus evaluations, etc.). The $82 million paid for audiologic tests represents about 0.02 percent of the Medicare budget for Part B services.
In 2017, Medicare paid slightly more than $24 million for vestibular tests (e.g., electro/videonystagmography [ENG/VNG, both bundled and unbundled codes], posturography, rotational testing). This total does not include any payments for vestibular-evoked myogenic potentials (VEMPs) that might be billed using the auditory-evoked response procedure code, which would be included in the total for audiologic diagnostic codes listed earlier.
|PROCEDURE||CPT CODE*||ALLOWED||PERCENT OF TOTAL|
|Tympanogram and Acoustic Reflexes||92550||246,667||18.52%|
|Air and Bone Conduction||92553||39,965||3.00%|
|Speech Reception Threshold||92555||13,680||1.03%|
|Speech Audiometry Complete||92556||39,513||2.97%|
|Stenger: Pure Tone||92565||1628||0.12%|
*CPT is a registered trademark of the AMA, 1995–2017
**Tympanograms are conducted independently (92567) and in combination with acoustic reflexes (92550); the total number of tympanograms is the sum of these two codes.
Table 3 shows a breakdown of the number of audiologic and vestibular procedures allowed for 2017 that were performed by audiologists, otolaryngologists, nurse practitioners, etc. Medicare rules specify that physicians should not submit charges to Medicare under their names for procedures conducted by audiologists. They can, however, submit charges for procedures performed by technicians, or for those they personally performed. In 2017, "comprehensive audiometry" was submitted under physician names approximately 25 percent of the time, with the majority of bills being submitted by otolaryngologists (CMS.gov, 2018b).
As shown in Table 3, nearly 90 percent of Medicare beneficiaries referred to audiology received comprehensive audiometry, and approximately 80 percent of beneficiaries were charged for a tympanogram (either combined with acoustic reflexes or alone). Beyond these two codes, the percentage of individuals receiving other diagnostic tests dropped significantly. The next highest number of diagnostic tests billed were comprehensive otoacoustic emissions at 6.54 percent and limited otoacoustic emissions at 5.11 percent. Interestingly, more patients received tone decay testing than tinnitus evaluations.
|Number of Beneficiaries Served||149.85||106||11–1,942|
|Number of HCPCS Codes||6.9||6||43,490|
|Number of Services Provided||311.97||212||11–3,954|
|Number of Services Per Beneficiary||2.03||2||1–9.78|
|Average Charge per Service||$93.30||$83.66||$20.82–$831.32|
|Average Charge per Beneficiary||$192.93||$159.58||$30.00–$4,977.88|
|Total Allowed Payments||$10,202.00||$6,629.00||$202.00–$184,516.00|
|Total Allowed Payment per Service||$32.91||$31.00||$13.00–$148.00|
Number of services refers to number of CPT or HCPCS codes submitted for each beneficiary. The average charge is the bill submitted by the audiologist for the services, while the allowed payments is the amount authorized by CMS to the audiologist for the service. Medicare pays 80 percent of the allowed charge while beneficiaries have a 20 percent co-pay.
Estimates of Audiologic Procedures Billed Only by Audiologists
In the traditional Medicare databases, payments to audiologists can be separated and analyzed. In total, the CMS database reveals 6,223 different audiologists submitted charges for 1,940,780 services to 932,408 Medicare beneficiaries in 2016 (CMS.gov, 2018a). However, these figures likely underestimate the total audiologic services due to services submitted under physician names. In addition, charges for audiology services provided as a hospital outpatient are not included on this list if the charges are submitted under the name of the hospital rather than an individual provider.
The CMS database on audiologists was reviewed and descriptive statistics (Table 4) were developed to provide a broad perspective on the services provided, patients served, and co-existing factors present in the patients seeking hearing care services from audiologists in 2017.
The mean number of beneficiaries served in an audiology practice is about three per week (149.85/year), with a median of about two per week, suggesting that the majority of audiologists are seeing two or less Medicare patients per week. On the other end of the range, there are practices that are billing Traditional Medicare for nearly 40 Medicare patients per week.
A wide range (1–25) of Healthcare Common Procedure Coding System (HCPCS) codes are used by audiologists, with an average of 6–7 codes used by each audiologist (CMS uses "HCPCS" in reference to all services including CPT and HCPCS codes billed by audiologists to Medicare). The low side of the range indicates some audiologists only use a single code for every Medicare patient (e.g. only comprehensive audiometry on every patient), whereas other audiologists use many codes within their practice. This likely reflects the type of services offered or following best practice protocols within the practice.
With respect to charges submitted, audiologists submit charges ranging from a few hundred dollars to more than one-half million dollars (average $25,000–$30,000). Payments are about one-third of billed charges, with audiologists collecting from $200 to $180,000 per year.
|AUDIOLOGIST A||AUDIOLOGIST B||AUDIOLOGIST C||AUDIOLOGIST D||AUDIOLOGIST E|
|Number of HCPCS||1||12||10||16||17|
|Number of Services||92||404||959||1,130||3,857|
|Number of Beneficiaries||92||62||233||531||1,113|
|Total Submitted Charge Amount||$7,820.00||$47,360.00||$82,855.88||$45,999.00||$344,470.00|
|Total Medicare Allowed Amount||$3,585.24||$25,212.65||$41,807.53||$39,043.41||$123,368.27|
|Total Medicare Payment Amount||$2,408.62||$19,485.97||$31,092.53||$28,355.29||$91,700.18|
|Average Age of Beneficiaries||81||75||79||75||74|
|Number of Female Beneficiaries||45||23||127||304||613|
|Number of Male Beneficiaries||47||39||106||227||500|
|% with Alzheimer's Disease or Dementia||21||47||10||9||9|
|% with Cancer||12||*||10||9||9|
|% with Heart Failure||24||*||18||16||15|
|% with Chronic Kidney Disease||27||26||24||24||22|
|% with Chronic Obstructive Pulmonary Disease||*||*||13||12||12|
|% with Depression||27||*||14||14||17|
|% with Diabetes||22||29||35||28||28|
|% with Hyperlipidemia||60||42||71||60||55|
|% with Hypertension||72||50||75||74||69|
|% with Ischemic Heart Disease||32||35||39||41||35|
|% with Osteoporosis||12||*||12||8||6|
|% with Rheumatoid Arthritis / Osteoarthritis||49||42||52||43||44|
|Average HHC Risk Score||1.1509||0.9845||1.2697||1.1189||0.9966|
* Indicate insufficient numbers on which to calculate a result.
At the provider level, Medicare databases show the number of beneficiaries served, number of procedures, and link patient demographic data and existing medical conditions to the audiologist providing hearing care services. Table 5 shows examples of data from five audiologists with very different Medicare characteristics.
Audiologist A evaluated 92 Medicare beneficiaries in 2017, but only billed a single CPT code (i.e., same single procedure). The total allowed amount for these 92 patients was $3,585, an average of about $39 per patient. Conversely, Audiologist E saw more than 1,000 Medicare beneficiaries and used 17 different codes. The total allowed for Audiologist E was nearly $125,000, an average of $110 per patient. Of course, these numbers do not reflect the reason for referral, the types of procedures performed, or the number of patient visits.
Table 5 includes several of the co-existing medical conditions for the patients seen by these five audiologists, which are fairly representative of the populations served by audiology (i.e., diabetes, cardiovascular concerns, dementia, and arthritis). To a lesser degree, patients served by audiology have cancer, kidney disease and osteoporosis. Audiologists may consider tracking these same co-existing conditions to ensure appropriate identification, management, and referrals for patients.
CMS tracks the co-morbidities of their beneficiaries and "scores" risk factors that they call Hierarchal Condition Categories (HCC) risk factors. They, then, correlate various risk factors to determine reimbursement for certain procedures and providers and to assess patient outcomes and manage costs. As shown in Table 5, the HCC scores for these five audiologists range from 0.9845 to 1.2697. However, based on the 2017 data, the risk scores for beneficiaries seen by audiologists range from 0.5134 to 4.4379, with a mean of 1.1950.
The fact that Medicare tracks the relationship between audiologists and these co-existing conditions should prompt continued discussion around best practices and the role of audiology in the broader health-care arena. What is the role of audiologists in the identification of risk factors for these conditions and the subsequent referrals to specialists? Are the historical or assessment paradigms employed within any given practice sufficient to make these decisions? For example, was the single procedure used by Audiologist A in Table 5 sufficient to properly counsel and/or manage the 21 percent of their 92 Medicare patients with Alzheimer's or the 27 percent of their patients with renal disease?
The audiologic view of Medicare is often focused on assuring compliance with billing and documentation rules. Perhaps it is time to elevate that view to include the broader role of audiology in health care, particularly as related to correlated conditions such as dementia, the risk of falls, or cardiovascular disease. This could be especially meaningful if audiologic processes can help prevent, reduce or identify sooner more costly conditions. Beyond the potential of direct access, and reducing Medicare costs through elimination of the physician referral requirement, the role of audiology in cost containment for Medicare for these co-existing or related conditions could prove to be powerful moving forward.
Medicare may be one of the great conundrums for audiology. For many practices, the Medicare population may constitute a high percentage of the payer mix, and for those practices with a focus on dispensing, it can be a primary target market. Conversely, the current payment framework that only recognizes diagnostic evaluations, based on CPT procedure codes rather than medical decision-making, is a significant challenge when attempting to deliver services. Throw in the requirements for a physician referral and a determination of medical necessity with the inability to opt-out of the Medicare program, and audiologists are often confused, if not irritated, with Medicare.
Despite these confusions and irritations, Medicare is a dominant force in the health-care market, representing more than 17 percent of all people in the United States with health insurance, and a model for most of the other health insurance programs. Thus, Medicare requires attention, both for the program in general, and with the intersection with audiology specifically. As a profession, understanding both the opportunities and challenges with serving Medicare beneficiaries is necessary for advancing the status of audiology in health care. Connecting hearing care services to other health-care concerns, much in the thinking of the emerging relationship between dementia and hearing loss, will require attention to best practices and a more global perspective within the patient care arena.