Winning Professional Jenga: How to Be a Successful In-Network Provider of Audiology and Hearing Aid Services

I have spent the majority of my professional life, as a clinician, administrator, and consultant, focused on managed care, specifically in the audiology space.  I work with practices, every day, as they try to navigate insurance and I try to help them solve their managed care issues. Through my education and work, I have learned a great deal and feel as though I have an extremely strong knowledge base, skillset, and background in the audiology revenue cycle process. As a result of my experiences, I feel comfortable making this statement:

Other than traditional Medicare, MOST practices and providers, regardless of the setting, should not be in-network with every Medicaid, Medicare Advantage, Commercial, and hearing benefit plan in their community. I find that the vast majority of managed care and, specifically, claims issues are created by the provider/practice and not the payer.

Let me tell you why I believe this: Many audiology practices and their administration and ownership do not invest the time and treasure required to effectively and profitably operationalize their revenue cycle processes.  As more and more health plans are requiring that providers jump through more administrative hoops in order to get paid in a timely manner, more claims issues and denials are arising. Payers are finding legal (and sometimes non-compliant) ways to drag payment out or not pay claims at all. This is why is it so important to have the provider side of the equation as buttoned up as possible.

There are practices, including large health systems and audiology private practices, who have mastered the insurance game.  In my experience, this is what practices have to have  in place to successfully (professionally, operationally and financially) participate in Medicaid, commercial insurance, or hearing benefit plans:

• Access to and/or investment in a healthcare attorney for contract review, negotiation and claims disputes.

• Modernized scopes of practice (this is accomplished through coordinated advocacy at the state level).

• An understanding of their practice breakeven rate and financial or budgetary goals, both short and long term.

• Training in compliance (required by all Medicare and Medicare Advantage plans), coding, billing, reimbursement, and insurance for ALL stakeholders (scheduling to payment), including especially, service providers.

• Office management systems and focused training on its functionality and capacities, including payer, claims and accounts receivable reporting.

• Staffing to support scheduling, insurance verification (cannot successfully be completed by front desk person), collection of payment, and claims processing and management.

• Leadership and/or ownership with a working knowledge and understanding of the medical and coverage policies, guidelines, and rights and responsibilities of each health plan that they participate with as well as the health plan portal and its functionality and limitations.

• Leadership and/or ownership with a foundational understanding of the revenue cycle process and oversight of managed care contracting, accounts payable and accounts receivable.

• Defined, no exceptions financial (payment of deductibles, co-payments, co-insurance, and non-covered services at time of visit) and practice policies.

• The required forms and documents, containing the required/appropriate language, including good faith estimates, advanced beneficiary notices, notices of non-coverage, upgrade waivers (as allowed by payer), insurance waivers, and bills of sale/hearing aid receipts (most I review do not meet the legal requirements of the state) for patient transparency.

• Care, pricing, and delivery models that reflect research evidence based, professional standards of care, which allow for amplification options within the hearing aid benefit, and which offer pricing and care that is consistent for all patients, regardless of their payment source or payer.

• Clear, honest, transparent communication, also in captioned video and written formats (as our patients are hard of hearing), about their rights and responsibilities as it pertains to their health plan and any coverage or benefit limitations or requirements.

• Clear documentation in the medical record of medical necessity for every item and service provided and of what occurred in each respective visit.

These steps can all be learned and accomplished.  It just takes investment of time and treasure!

If an audiology practice cannot do or accomplish these things listed above, they should strongly consider becoming an out of network provider for Medicaid, Medicare Advantage and commercial health plans. The participation decision should be the result of research on the plan and its allowable rates and the running of a SWOT, referral and financial analysis for each individual payer they are contracted with.

Without following these steps, the claims problems will remain and may continue to grow as plans use more AI and predictive analytics in their aspect of the process.  Billing and claims processing is always a “junk in, junk out” situation. The provider and practice will always have the largest role in revenue cycle success or failure.  Problems aren’t solved by outsourcing billing if the information provided to the biller is incorrect or incomplete.

Next time, I will address how to excel at being an out of network provider (which is also not without required processes or procedures to be transparent and compliant).