Question
Since audiologists cannot opt out of Medicare, is there any way audiologists can provide hearing tests, such as air conduction, at no charge for the purpose of a hearing aid purchase? Hearing aid dispensers are able to do so, but from what I read, it doesn't appear that we can.
Answer
Good question. That's a really sticky situation, and there are different ways to look at it. I'm going to give you a couple of perspectives, but keep in mind that there is a lot more to it than simply opting out or trying to do something at no charge.
Say you have a patient that comes in, having never been seen by anyone before, and they say they have a hearing problem, want a hearing test and a hearing aid, but do not want to see their physician. This happens quite commonly. In my opinion, this is not official from ASHA or AAA, because we cannot opt out, you would need to have them sign an advanced beneficiary notice (ABN) and make them aware that they would be liable for the test or the outcomes. Then you would need to submit the bill to Medicare with a GX modifier, which states that the hearing test does not meet the threshold of medical necessity and the patient is refusing a medical examination. By using this modifier you are able to report what you are doing and the rationale behind it, which is that the patient refused to see the primary care physician.
Medicare does require all beneficiaries and providers to report everything to Medicare except for what is statutorily excluded; a hearing test is not statutorily excluded. It will not meet the level of medical necessity, but it is still a covered service. Now, if the person comes in and wants a hearing test just as an annual check-up, due to the lack of opt-out ability you are still bound to report that service with a GX modifier because Medicare has an interest in knowing what is going on with its subscribers. To some extent, they are very interested in protecting subscribers and enrollees from potential abuse. That is part of the rationale behind all of this.
Let’s consider this scenario. A patient comes in for an annual hearing test and does not want to get the referral from his doctor. The audiologist does it and does not sign an ABN and does not bill Medicare. The patient later comes back and says, “Oh I forgot to tell you, I have a secondary payer that will cover this regardless of Medicare's requirement for physician referral as part of the benefit package to me. I need to have you bill Medicare to get denial so we can send it and have the secondary payer pay so I won't have to pay.” Well, the ABN was not signed on the date of service and the bill was not sent in on the date of service. The patient may have the right to want to bill the secondary payer, but it is going to cause a very sticky situation for the audiologist in that instance. My guidance is to be very careful. Play it straight. Sign the ABN and send the bill to Medicare with the GX modifier.
Editor’s Note: This Ask the Expert was taken from the eSeminar Reimbursement: The 2012 Perspective published on 2/9/2012. To access the recorded course, please go here.
