Question
As an audiologist, I have an idea of what technology and services I think are "medically necessary." However, rarely does Medicare agree with me on this issue. I have patients who cannot afford the medical necessities Medicare does not cover. Can you outline what Medicare defines as "medically necessary" and how that definition affects our practice?
Answer
Dr. Kim Cavitt: This is a good question, and one that is a little hairy. Medicare pays for things that are medically necessary only. They do not pay for annual or routine hearing testing. They do not pay for anything related to the purchase or maintenance of a hearing aid. There is a lack of definition in our field, unfortunately, as to what is medically necessary when it comes to aural rehabilitation or tinnitus management.
Dr. Steven White: Proposed legislation does speak to this issue, however. When it comes to rehabilitation services under Medicare, if the patient has a functional limitation and there is an expectation that the patient's functional abilities will improve if a patient could make better use of a hearing aid and aural rehabilitation such as speech reading, then that would be covered. If the patient does improve in 30 days, typically, then the provider and Medicare will say that we have given it our best shot, and the on-going treatment is no longer deemed medically necessary.
Dr. Kim Cavitt: Unless we obtain the provision of direct access, we are still going to need a physician's order to carry out our services to Medicare beneficiaries. Therapy will still have to have a written plan of care that is reviewed by a physician, and then managed and certified by a physician. You will still have to document and report on the evaluation, diagnosis, plan of care, and results of the treatment. The current reimbursement for comprehensive audiological evaluation is $83. I ask you, can you do all that for $83? This is why direct access is crucial for audiologists. It will help us define, more independently, what is medically necessary for our patients. The best way to define what is medically necessary is to become involved in the current and ongoing legislation for Audiology through your professional organizations.
Editor's Note: This Ask the Expert was taken from the live e-seminar The Potential Risks Versus the Need for a Comprehensive Medicare Benefit recorded 6/16/2011. To access the complete course, please go here.
Kim Cavitt, Au.D. spent nine years as a clinical audiologist and preceptor at both The Ohio State University and Northwestern University and spent two years as the Director of Professional Relations at HearPO. For the past ten years, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. Audiology Resources, Inc. provides comprehensive operational and reimbursement consulting services to hearing healthcare clinics, providers, organizations, buying groups, and manufacturers who want to be better equipped to compete in the managed care and healthcare arenas. She also currently serves on committees through ADA, AAA and ASHA and is an Adjunct Lecturer at Northwestern University.
Steven C. White, Ph.D., CCC-A, is the Director of the Health Care Economics and Advocacy at the ASHA, and has spent thirty years in government relations at ASHA. White, an ASHA Fellow, is ex officio of the Health Care Economics Committee and staff liaison to the Current Procedural Terminology Editorial Panel and the Relative Value Update Committee. He is co-author of Health Plan Coding and Claims Guide, Negotiating Health Care Contracts and Calculating Fees, Appealing Health Plan Denials, Medicare Handbook for Audiologists and Medicare Handbook for Speech-Language Pathologists. He holds a M.S. in speech-language pathology and audiology from Ithaca College and a Ph.D. in audiology from Wayne State University.
