Frequently Asked Questions: H.R. 2330 - Medicare Audiology Services Enhancement Act of 2013
Does H.R. 2330 move audiologists away from autonomy?
Health care and Medicare are moving towards a medical/health home and general physician oversight for all specialty care. In general, the physician (or non-physician practitioner including nurse practitioner, physician assistant or clinical nurse specialist) is becoming the gatekeeper for referrals to all specialty services. This bill moves audiology forward in the current health care system by recognizing audiologists as diagnostic and treatment providers, able to receive Medicare reimbursement for the professional services they provide.
Will the bill decrease access to services?
Currently, the requirement for providing covered audiological services to a Medicare beneficiary includes an order from a physician or non-physician practitioner (nurse practitioner, physician assistant or clinical nurse specialist) prior to the audiologic evaluation being performed. At this time, the Medicare benefit only covers diagnostic services performed by an audiologist, not treatment services. The proposed legislation will allow Medicare beneficiaries to receive diagnostic and treatment services from the audiologist. Expanded coverage provides increased access to care.
Will a dispensing audiologist be required to unbundle their services?
Services associated with the dispensing of a hearing aid (examination, prescribing or fitting) are statutorily excluded from Medicare coverage and are not affected by the proposed legislation. The Medicare Benefit Policy Manual, Chapter 15, section 80.3(F), specifies, “Services for the purpose of hearing aid evaluation and fitting are not covered regardless of how they are billed.” Therefore, the decision to bundle or unbundle services related to the hearing aid rests solely with the dispensing audiologist.
Will I lose the ability to manage my patients care due to physician oversight?
Audiologists will still maintain the ability to use their clinical judgment and expertise in treating the patient. The audiologist, after examining the patient will develop a plan of care tailored to that individual, and then, in accordance with Medicare guidelines submit that plan of care to the beneficiary's physician (or non-physician practitioner including nurse practitioner, physician assistant or clinical nurse specialist).
Won't the establishment of a plan of care delay my ability to treat the patient?
Plans of care, a standard practice for treatment providers, are a Medicare requirement for the reimbursement of treatment services, including dialysis and diabetic care. Generally, the Medicare Benefit Policy Manual allows 30 days from the initial visit for the development and/or approval of a plan of care. Because audiologists would remain under their own benefit category, the requirements for the plan of care can be tailored to address the clinical practice of the audiologist and take into consideration same-day treatment, such as canalith repositioning. The flexibility of the current Medicare rules for plans of care allow treatment to occur for a short duration while the plan of care is under discussion with the physician or non-physician practitioner (nurse practitioner, physician assistant or clinical nurse specialist).
Won't H.R. 2330 place audiology services under the therapy caps?
The section of the Social Security law that places financial limitations on outpatient therapy services is not referenced in H.R. 2330 and does not apply to audiology services. The section of law related to therapy caps specifically references physical therapy, occupational therapy and speech-language pathology services. Congress is looking for ways to repeal and replace the caps, not expand it to more providers. The Comprehensive Audiology Bill does not include amendments or references to therapy cap law, and in the absence of a law enacted by Congress, CMS does not have the authority to impose additional therapy caps to providers not identified in the law. Services provided under the therapy cap are specifically tracked by CMS through the use of modifiers on the claim form that identify services provided under plans of care for physical therapy (GP), occupational therapy (GO), or speech-language pathology (GN).
Might H.R. 2330 have the unintended consequence of reducing reimbursement levels for audiology services?
The oversight of Current Procedural Terminology (CPT) codes occurs by the American Medical Association, and codes are subject to scheduled review and revaluation, generally in 5 year increments. Audiology use of treatment codes already in use by other health care professionals will not automatically trigger a revaluation of these codes. Most of the codes for the services covered under H.R. 2330 are already valued, including intraoperative monitoring, canalith repositioning, and vestibular rehabilitation. The legislation will allow coverage and payment for audiologic rehabilitation and allow for audiologists to bill Medicare for services they are often providing without consistent reimbursement.
Will the legislation require audiologists to bill Medicare for hearing aids?
Hearing aids are not covered under this legislation. Hearing aids and related services are statutorily excluded as a covered Medicare benefit. ASHA's legislation would not impact the current rules related to dispensing hearing aids.
Will audiologists have to see all Medicare beneficiaries?
Nothing in the bill requires audiologists to participate in Medicare. By expanding the range of covered services, Medicare beneficiaries will have greater access to coverage of intraoperative monitoring services, vestibular and audiologic rehabilitation. However, if an audiologist does not want to participate in Medicare they can determine to limit services for Medicare beneficiaries to hearing aids and related services, and not Medicare covered benefits. The Medicare Benefit Policy Manual includes the coverage of hearing aids as an automatic opt-out, because Medicare's rules do not apply to items or services that are categorically not covered by Medicare.
Why is ASHA pursuing legislation that other audiology groups oppose?
ASHA members signified that one of the highest advocacy priorities should be to promote improved public and private coverage policies and reimbursement rates for audiologists and speech-language pathologists treating patients across the age span. A comprehensive Medicare audiologic reimbursement benefit to include both diagnostic and rehabilitative services is a major aspect of this top advocacy priority.
ASHA did due diligence in looking at what was the best way to increase Medicare beneficiary access to hearing health services. Our legislative consultants, as well as senior members of Congress and senior committee staff of the Energy and Commerce Committee, indicated that this approach would have the best chance of support. We respect that ADA and AAA have their own vision of what is best for the profession and look forward to seeing their legislation introduced so that we can determine what approach resonates best with Congressional leaders and what can pass into law. ASHA believes expanding the scope of audiology services covered by Medicare is possible at this time while achieving direct access or limited license practice is just simply not possible in the current political and health reform environments.
No non-physician professions have gained direct access or limited license practice under Medicare in more than a decade. Even the profession of physical therapy with more than 200,000 practitioners and with a clinical doctorate requirement were unable to make significant headway in obtaining direct access and have abandoned that legislative approach.
What is the position of members of Congress, the medical community, and other audiology organizations regarding this legislation?
The comprehensive benefit legislation was introduced by Representative Gus Bilirakis (R-FL), a member of the House Energy and Commerce Committee and as of June 13, the Bill has garnered bipartisan support from eight additional Representatives; Representative Butterfield (D-NC), Representative Capps (D-CA), Representative Guthrie (R-KY), Representative Michaud (D-ME), Representative McKinley (R-WV), Representative Gerlach (R-PA), Representative Huizenga (R-MI) and Representative Meehan (R-PA). In addition, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) has come out in favor of the legislation. Though a comprehensive benefit has been part of legislation proposed by other audiology organizations, those groups have focused on other priorities in their recent legislative activities.
What are the other advantages of moving toward Medicare reimbursement for treatment services provided by audiologists?
Audiologists are currently paid under the Medicare physician fee schedule. Congress is looking to replace this system with one that is more sustainable. The proposed new system would set a floor for payment and require audiologists to submit quality and efficiency measures and patient outcomes in order to receive bonus payments. Current quality measures for audiologists do not appropriately reflect the work of the audiologist and the audiologist's process related to referral back to a physician. It is nearly impossible to develop quality and outcomes measures associated with a diagnostic benefit when the person diagnosing the care is not responsible for treating the condition that was diagnosed. Comprehensive benefit would allow for billing of both diagnostic and rehabilitative services and therefore allow for the development of quality measures that better capture the services provided and patient outcomes. In addition, many audiologists bundle all of their services into the cost of a hearing aid, because it is difficult to separate rehabilitation services that are not currently covered. Comprehensive audiology legislation would allow for unbundling, because professional services would be reimbursed.
How will comprehensive coverage improve access for Medicare beneficiaries?
Audiologists who wish to provide services, such as auditory or vestibular rehabilitation, to Medicare beneficiaries now use an Advance Beneficiary Notice (ABN) that indicates the service will not be covered by Medicare if provided by the audiologist. Vestibular rehabilitation and auditory training are currently covered under the Medicare program when provided by other providers. Most Medicare beneficiaries seek the covered provider for economic reasons, so audiologists are currently losing at least some patients. This would be less likely to occur if comprehensive coverage of audiology services were in place.
What additional services would be covered under comprehensive coverage?
Audiologists would be able to provide professional evaluation and treatment services to Medicare beneficiaries. Additionally, those audiologists trained to perform intraoperative neurophysiological monitoring will be eligible for reimbursement under this legislation. The specifics of other coverage, beyond the four broad categories outlined in the legislation, will be determined through the development of regulations.
Will physicians continue to determine medical necessity for audiology services?
Just like all other non-physician providers under the Medicare program, audiologists would still be able to determine medical necessity of services that they provide. Audiologists will be required to develop a plan of care and submit the plan of care to the beneficiary's physician or non-physician practitioner. A physician order or referral from a non-physician practitioner (nurse practitioner, physician assistant or clinical nurse specialist) will also be required as a condition for Medicare reimbursement.
Does ASHA continue to support direct access?
The direct-access legislation as currently proposed by other audiology organizations is likely to create an audiology benefit that would define audiology services as strictly diagnostic in nature. It is also unlikely to pass in the current legislative climate that is moving toward health care delivery models based on medical/health homes and care coordination. ASHA believes our member resources are most effectively applied to passing comprehensive coverage of audiology services.
Are audiologists currently able to bill under the Medicare program?
Although audiologists are educated and trained to provide both diagnostic and treatment services, under the Medicare program, audiologists are restricted in their ability to bill for the full range of their professional services and can only bill for diagnostic procedures to rule out a medical condition. The bill allows Medicare to expand coverage of treatment services when performed by an audiologist, though the specifics of such coverage, beyond the four broad categories outlined in the legislation, will be determined through the development of regulations.
What is ASHA's position on direct access and the 18x18 campaign?
While ASHA supports professional autonomy for the audiology profession, we believe that we are more likely to achieve meaningful success if we work within the political reality of what is feasible to accomplish on Capitol Hill and a strategy that is consistent with the future of Medicare billing practices. After lengthy discussions with ASHA's legislative consultants, members of Congress--as well as ASHA's Health Care Economics Committee, the Audiology Advisory Council, and ASHA's Board of Directors, ASHA believes that our advocacy resources are best applied to passing comprehensive benefit legislation. This legislation not only helps audiologists, it helps patients.
When the Medicare regulations refer to certain professions that can "opt out," what do they mean by that?
Though some people use the term "opt out" to mean the same thing as "not participate," the terms are different in Medicare statute and regulations. "Opting out" is an option for physicians and a small number of other professions that allows for the provider to accept payment from the Medicare beneficiary, and prohibits the beneficiary or provider from billing Medicare for those services. The services are 100% paid for out-of-pocket by the beneficiary. H.R. 2330 does not change current Medicare rules, which allow audiologists to (1) participate fully, (2) accept Medicare beneficiaries as a non-participating provider, which means the audiologists collects the Medicare fee from the beneficiary, and the beneficiary is paid directly by Medicare, or (3) not see any Medicare beneficiaries at all. Certain professions, such as physicians and non-physician practitioners like physician assistants and nurse practitioners have the ability to "opt out" and accept payment from Medicare patients without being subject to the Medicare Physician Fee Schedule rates. Audiologists are not currently included on that list of providers who are given that option. There are pros and cons to having the ability to "opt out." A provider who chooses the opt-out option must enter into private contracts with all of their Medicare patients and is prohibited from billing Medicare for 2 years, thus reducing access to typical Medicare beneficiaries unwilling to forgo Medicare coverage of their services. It is estimated that less than 2% of providers who have the option to "opt out" choose to use it. It you are interested in more information about the Medicare opt-out option, you can download the Medicare Benefit Policy Manual [PDF] from the Medicare website.
What type of services will be covered under the legislation?
No legislation describes every procedure that it will cover, but we believe the language is broad enough that once passed, the subsequent regulations will allow for coverage of current and future treatment services that are most important to audiologists.
What can I do to support this legislation?
If you are interested in supporting the Comprehensive Benefit legislation, request that your member of Congress cosponsor the bill.
Director of Federal and Political Advocacy