To: Audiology colleagues nationwide
From: Richard E. Gans, Ph.D., President, American Academy of Audiology
Problem:
During the past several years, as vestibular CPT codes went through a significant increase in reimbursement, there has been a growing interest in vestibular and balance testing. This was only natural. In the past two years however, we have seen a very concerning trend by non-medical businesspersons to get into the "dizzy" business through highly questionable practices. These improper business and billing schemes, specifically through the federal Medicare program have now caused the Medicare carriers and the Centers for Medicare and Medicaid (CMS) to scrutinize all vestibular testing. This has created a significant problem for legitimate practitioners in California causing the recent postings seen on the AAA Soundoff.
I have been working with National Heritage Insurance (NHI), the Medicare carrier in California dealing with the fraud and abuse that has been occurring in that state over the past year. National Heritage contacted us about 9 months ago due to the exponential increase (700%) in vestibular claims submitted to Medicare. The dollar amounts were staggering. They went from $1.3 million to $13 million dollars in less than one year!
NHI knew the problem was not due to Audiologists, ENT's or Neurologists. The problem was clearly related to mobile testing conducted by Independent Diagnostic Testing Facilities (IDTF) using unlicensed and untrained employees indiscriminately testing Medicare patients in retirement centers, Adult Living Facilities and so on. The tests were "read" by an off-site physician who served as the "medical directors". There was no medical necessity and the tests were over billed and grossly over utilized with the same patient sometimes being tested multiple times within a month or two.
We helped them try to control the problem by suggesting that they close the door on the IDTF's, which would insure that patients who really needed testing would have access to Audiologists and other appropriate physicians. The IDTF's somehow convinced National Heritage that they would have audiologists perform the test. They did not. They had some audiologists off site "reading" the results. Medicare claims continued to mount with billings for 7-8 units of 92547 - vertical electrodes. The AMA states this should only be billed for 1 unit. Optokinetic testing was being billed for 4 units when it should be billed for 1 or possibly 2 at the most. The codes for active and passive rotation tests 92646 and 92548 computerized dynamic Posturography were being billed by facilities that did not even have the equipment. NHI also had the marketing and advertising materials used by the promoters of equipment or unethical testing practices promising outrageous returns to physicians for getting into the "balance business". They are also monitoring the websites of equipment manufacturers to look for those that are promoting this unethical behavior as a business model.
In response to the continued problems and abuses NHI stopped payments to any facilities where more than one (1) unit of any test was billed. This action by NHI was to all practitioners, physicians, hospital, and medical centers, not just audiologists. They withheld payment pending proof of medical necessity. This is a problem because typically 4 calorics are performed.
Action:
Last week I had a one and a half hour teleconference with the NHI Medical Director and their key staff for the entire state. I provided them with a comprehensive overview of the importance of access to vestibular testing for legitimate patients and the need to protect those practitioners from being unfairly penalized. They assured me that they would open up the reimbursements as we recommended along with other suggestions. We are in touch on a weekly basis to ensure that the corrections are being made. In the meantime, if you do receive a request for proof of medical necessity it is important that you quickly do so in order to receive payment. This will be resolved, but the illegal and unethical practices of these operators are causing a temporary problem. Until AAA together with NHI and CMS can clean out the system it may be a bit bumpy. Audiology and the Academy are being recognized as leaders in correcting this problem. NHI is apologetic about the problems but is working to fix them. Ultimately, this will be positive for audiology as we educate NHI and CMS that Audiologists are a key entry health care professional for vestibular and balance patients.
Unfortunately these "balance businesses" are cropping up in Arkansas, Florida, Colorado, Missouri, Texas and elsewhere. If you are contacted or approached by this type of a business I urge you to contact us. These businesses must not be allowed to desecrate our reputation, especially when we are on the brink of direct access. More importantly, NHI has told me that the CMS-FBI fraud and abuse operatives have now identified these businesses as prime targets of investigation. The American Academy of Audiology along with other concerned organizations, including the American Academy of Otolaryngology-Head and Neck Surgery and the American Academy of Neurology will be working closely with CMS and the Office of the Inspector General (OIG) to ensure a successful resolution to this troubling situation. Our patients, the Medicare program and our profession must be protected from this abuse.
