Private Practice, Bundling/Unbundling, and CPT Codes: Interview with Elizabeth Protti-Patterson, AuD
Douglas L. Academy, AuD, spoke with Dr. Protti-Patterson about private practice, bundling/unbundling, CPT codes, speech-in-noise tests, professional multi-tiered service packages, and more.
Academy: Good morning, Liz. Thanks for sharing your time with me!
Patterson: Hi, Doug. Always a joy to speak with you.
Academy: How long have you been in practice, Liz?
Patterson: Well, it's been about 30 years. Seems hard to believe!
Academy: I agree! You and I have about the same time in grade, and it's gone by quickly. Nonetheless, as you know, I'd like to speak with you about the multitude of changes that have occurred during our time as audiologists.
Patterson: Absolutely. The way we practice in 2014/2015 is not at all the way we practiced decades ago. Frankly, I think we need to modify the way we bill to remain competitive and to maximally serve our patients.
Academy: For example?
Patterson: Well, let's start with CPT codes. The issue to me is that if we only bill services for which we have a CPT code, we're not doing enough work! For example, to adequately diagnose hearing loss and dispense hearing aids, we need to test speech-in-noise listening ability—and there's no CPT code for that—so most professionals don't do the test.
Academy: I have to agree wholeheartedly. To me, the single most important test we do to assess the patient's ability to understand speech-in-noise (SIN) is a speech-in-noise test. If we don't perform the test we're guessing—and that's not in anyone's best interest! Further, I would say comparing SIN results with different amplification settings is the only way to really know if we've helped the patient with their primary complaint!
Patterson: Absolutely. And as we dig deeper, we see that most audiologists don't have or offer their patients an aural rehabilitation program. Of course the reason for this is the same as the lack of SIN tests. There is no CPT code, hence we cannot charge for our time, hence, very few people are offered AR programs.
Academy: And I would add the single most important event after the fitting is a group or individualized AR program, so the patient not only learns to maximally use their hearing aid, but they learn how to listen as their brain adjusts to their fitting.
Patterson: And we can dig still deeper and I suspect most audiologists aren't doing verification and validation, even though some insurance companies do have HCPCS codes for these procedures, and the same situation exists with respect to real ear measures and so much more. Regardless of whether there is insurance coverage, these procedures are part of the best practice services that are bundled into the cost of the hearing aid in the first place. Otherwise why is there a mark up to the cost of the hearing aid in the first place?
Academy: Interesting point. It's clear that two-thirds of all audiologists don't verify and validate. Indeed, Dr. Kochkin and colleagues wrote about that in their June 2011, Hearing Review cover story—in which they reported (based on a sample size of some 800 practitioners) that two-thirds do not use verification or validation (V&V) measures, which means they use that other protocol.
Patterson: Which protocol is that?
Academy: They guess!
Patterson: And if I recall they also showed how it takes less time to use V&V than to not use it?
Academy: Exactly. They said that for those practitioners who used V&V, the typical patient required 1.2 fewer visits and further, they showed that 76 percent of patients with "above average success" were fit in 1 or 2 office visits, using V&V.
Patterson: That's powerful evidence. But again, seems to me the reason two-thirds of all audiologists aren't doing V&V is the lack of a code in many cases!
Academy: That seems to be the case. So what do we do?
Patterson: Well, it makes sense to figure out which services must be offered to do the work appropriately and that work is defined in the best practice statements. It seems we need to charge for each of those services so we can afford to perform them. If we remain a "CPT code-driven profession" we're likely not going to be competitive as the patients believe they just need to acquire the device itself. They don't know about the very important tests and services. And frankly, when they look online and at the big-box stores, they see and purchase hearing aids for less than our bundled prices, so to be competitive, we simply have to itemize and then we need to charge the patient (as all doctors do) for the services performed.
To be clear, we should bill for the CPT/HCPCS codes we perform, but I think we should also bill them for best practice services that do not have a code assigned to them. Of course, we need to review that with the patients and tell them which services are likely to be paid by their insurance and which services aren't…but payment should not drive clinical decisions! In fact, if we're going to remain competitive, we have to realize the advantage to seeing a hearing doctor is the expertise they have, and if that expertise is not being used, why see them?
Academy: You make a compelling argument for unbundling/itemizing! And is that how you run your office?
Patterson: At present, REM Audiology dispenses hearing aids not only to private pay patients but to patients that have insurance coverage. We do work through one managed Medicaid insurance company and several commercial insurance companies. Our itemizing protocols at this time involve insurance companies. For those insurance companies that pay us for the hearing aids, we itemize the cost to consist of the hearing aid itself plus service codes such as dispensing fee, hearing aid examination and selection, hearing aid assessment, batteries, and earmolds. There are other service codes, including hearing aid checks, electroacoustic analysis and hearing aid fitting/orientation/check.
It is important for each center to get the fee schedule for services from the insurance companies, which admittedly, may not be all that easy. It is of course preferred to be able to get the codes and reimbursement directly from the insurance company. In some cases you need to give a list of the codes you wish to use to the carrier before they give you any information.
For those insurance companies that pay a dispensing fee only, REM Audiology will bill the insurance company or the patient directly for services performed after the time span that the insurance company includes in the dispensing fee. REM's present unbundling protocols are only skimming the surface of what our profession can and should be doing. We are planning and thinking for the future and it's pretty clear that audiology needs to emphasize services that differentiate us from the big-box stores.
I believe we need to be "transparent" with patients, including our private pay patients. Patients need to know what portion of their monies pay for the hearing instrument and which portion pays for services. They also need to know that "best practices" are not being compromised but are being included in the service section of the contract. I feel that 100 percent itemizing (meaning that patients pay only for the instrument and then purchase services "ala carte") may result in patients not purchasing services that constitute best practices, so we have to be cautious. "A la carte" strategies may result in less than optimum benefit from amplification. However, it's important to keep in mind, Oxford dictionary defines best practices as "commercial or professional procedures that are accepted or prescribed as being correct or most effective." The sale of hearing aids should not be distilled to a level that excludes best practice strategies.
Academy: I follow your argument, but to me, the model you're advocating is more of a "tiered-pricing" model. Is that right?
Patterson: Yes. I am recommending tiered pricing instead of itemized pricing. The different tiers are not technology related, but are related to the amount of services a patient wants to purchase above best practice strategies and importantly, in my model, even the lowest tier receives best practice servicing. Further, the patient can purchase a premium hearing aid at the lowest tier level. So to be clear, we charge more at higher tiers not because of the technology level, but because of the service package.
Academy: Well, although I'm certain there are many ways of itemizing, the approach you've described (tiered) makes intuitive sense. And so tiered pricing allows the patient to pick their technology level and their service level. I get it, and it makes sense…but will it work in the marketplace? Can you give me an example of the multiple tiers you might offer?
Patterson: Sure. Let's assume Tier One is the lowest level of service and the shortest warranty. However, even this tier includes what the Academy would consider best practices, such as real-ear measurements, COSI, and APHAB. The higher tiers might include follow-up services after the first year, such as regular clean and checks, reprogramming, free wax guards, extended warranties, free batteries, and possibly a discount off their next purchase of a hearing aid from REM Audiology and more. It will be up to the individual center to define such services.
And most importantly, the different tiers would be available for each product! The intention of the tiered strategy is to remain transparent with the patient; to maintain cost per hour needed by the professional to maintain their practice regardless of the tier level chosen by our clients; to preserve best practices at all levels; to offer advanced hearing aids at all tiers; and to become competitive with insurance companies and third-party payers.
So yes, some people are just going to want to buy the least expensive product, but those people weren't going to buy a very good instrument anyway as they want the cheapest…so that's fine, it's their decision, let them but the cheapest! In fact, I think the cost of the hearing aid should be transparent and that way we would appeal to consumers, as they are the ones that drive the economy! Perhaps our standard professional office protocols should address the words and emotions we use to suggest if they only want to spend $300 to maybe $500, they can do exactly as they wish, but here's why we think it makes good sense to buy an appropriate and professional service program…
Academy: Excellent idea. I know so many audiologists are struggling with exactly these issues right now. Thanks for sharing these very important ideas, Liz.
Patterson: My pleasure, Doug. I think this is something we all need to discuss and we need to individually find the protocol that works best for each of us, given the exact situations we're in. But overall, we absolutely need to be competitive.
Dr. Patterson thanks Tad Zelski, Stephanie Wolf, Barbara Rosen, and John McNamara for their input and thoughts on tiered levels of service.
Elizabeth Protti-Patterson, AuD, is an audiologist and practice owner of REM Audiology Associates, in Voorhees, NJ and Philadelphia, PA.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology and the director of public relations with Oticon, Inc.