Reimbursement for Tinnitus Treatment

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Answer

First, it is wise for patients to understand their insurance benefits for tinnitus treatment. Insurance companies also are required to publish procedures for filing an appeal if the treatment is not stated as covered. Find out what services are covered and which are not by checking the member benefits handbook, the insurance plan's web site, and/or calling the health plan administrator. Be aware of the processes involved in requesting and obtaining coverage. Consider contacting the health plan to determine coverage as well as the patient's financial liability prior to starting any tinnitus treatment. And if a patient chooses to file an appeal for a treatment not covered, they need to make sure and follow the rules and timelines outlined in the appeal requirements.

If the insurance company denies the tinnitus-related medical services claims, here are suggestions to help you work with the patient in appealing the decision:

1. The health plan should have an established appeal process to follow. Determine where the appeal letter should be sent. Check the denial letter or member handbook to find the correct address and recipient or department, and send the letter "certified mail with return receipt" to guarantee delivery.
    
2. Determine why the insurance company denied the claim, and address this specific concern in writing. The reason for denial will help determine the focus of the letter. Was it because the services were experimental, not medically necessary, or simply not covered under the member benefits? You, as the hearing car provider, may need to write a letter in support of the treatment choice.
    
3. For an appeal letter, be sure to specifically address the reasons for the denial stated in the correspondence from the health plan. Include clinical information, doctors' opinions, and studies published in medical journals. Be sure to show how the treatment you recommend is the best choice. Your opinion as a specialist in treating tinnitus will receive greater weight than those of non-specialists. Opinions of doctors who specialize in treating similar conditions also are relevant. Be direct. State specifically what you would like the health plan to cover. Also, include a brief synopsis of what steps the patient has already taken to treat the tinnitus, including when the patient first experienced the condition and other pertinent health history.

Discuss the potential costs of not treating the tinnitus. For example, many people with tinnitus report increased stress or sleeplessness, which can affect other body functions as well as quality of life. Include a brief statement about why you believe the treatment you are seeking is medically necessary. Attach any relevant correspondence between the patient and insurance company or physician, if available.

If further attempts at appeals continue to prove unsuccessful, you may suggest that your patient contact his or her company's human resources representative, or union representative, as appropriate, to discuss the denial. These professionals may contact the health plan on the patient's behalf. Consider also contacting organizations that may provide additional funding resources. If the patient has a Medical Savings Account, this may be a viable financial option, as tinnitus treatment and devices may qualify as covered expenses.

Casie Keaton, Au.D., CCC-A is a Clinical Sales Manager with Neuromonics and has extensive experience treating tinnitus patients. She has research published in the area of psychoacoustics.

For more information about Neuromonics visit www.neuromonics.com or the Neuromonics Web Channel on AudiologyOnline.