Private Health Plans Frequently Asked Questions: Audiology
How do patients appeal a denied claim?
If you choose to assist in the appeal:
- Meet with the patient or patient's family to review their health plan. Some states do not permit the provider to participate in the appeal process.
- You could prepare a letter that states why the service is medically necessary for the patient. If possible, the letter should include a medical diagnosis or referral from a physician as proof that the patient needs the evaluation/treatment.
- Additional appeal levels would include an independent organization's review of the case, contact with the state insurance commissioner, or legal action.
- ASHA's Health Care Economics and Advocacy Team created "Appealing Health Plan Denials" to assist you in creating your letter of appeal. This beneficial document can be purchased via the ASHA online store or by contacting ASHA's Product Sales at 1-800-498-6699. Ask for Item # 0112475.
Can the services provided by a Clinical Fellow (CF) be submitted to a health plan for reimbursement?
There is no uniform standard for private payers, so we look to Medicare's guidance.
Federal Medicaid regulations define CFs as qualified speech-language pathologists and do not mention licensure. However, a state Medicaid program can supercede Federal regulations when the state requirement is more stringent. Thus, Medicaid programs could require licensed practitioners and disallow non-licensed CFs.
Where can audiologists obtain a complete listing of codes, both procedure and diagnostic?
ASHA's "Health Plan Coding and Claims Guide" provides resources on coding, billing, appeals, denials, and other helpful information. This guide is available through the ASHA online store or through ASHA's Product Sales at 1-888-498-6699. Ask for Item #0112486.
A list of CPT codes with short descriptors and associated fees for speech-language pathology and audiology can be found in the Medicare Fee Schedule or the Superbill for Audiology Practice [PDF]. Go to the American Medical Association (AMA) Web site to order the official CPT Manual.
What is a "superbill?"
A superbill is a time efficient form to document services, fees, codes, and other information required by health plans. Models are available for download by clicking Superbill for Audiology Practice [PDF].
What is a CMS 1500 form?
Non-institutional providers and suppliers use the CMS 1500 form to bill Medicare Part B services, Medicaid, and private health plans. Diagnosis codes are inserted in Sections 21 and 24E. CPT codes are inserted in Section 24D. You may print black and white copies through the CMS Web site or obtain copies from your local Medicare carrier, local printing companies, or the Government Printing Office (212-512-1800).
How do I establish fees for audiology services?
You may refer to the Medicare Fee Schedule for a general idea of what Medicare reimburses for specific procedures. It is important for you to know that Medicare rates reflect a budgetary constraint and may not reflect current market rates. You can also purchase historic fee data from medical coding publishers. ASHA's "Negotiating Health Care Contracts and Calculating Fees" publication (available at the ASHA Online Store; Item #0112450) also offers national charge data to help you evaluate your fees by comparing your charges to those of other practitioners nationwide.
Discussing fees with other local professionals may be construed as price-fixing. Setting prices in collusion with colleagues is illegal.
How should audiologists document their treatment?
Different facilities or agencies have different requirements for how services are to be documented (e.g., SOAP notes, narrative) and where notes are to be maintained (e.g., carbonless copies, writing notes directly in the patient's chart, electronic medical record).
Clinicians must consider the needs of the audience for which the documentation is intended. Oftentimes, a variety of related professionals and claims reviewers will read the assessment report, treatment plans, and discharge summaries, so the clinician needs to ensure that what they write can be understood by an audience of varying backgrounds and experience.
Payers may have documentation requirements of their own, including the information they want to see when reviewing a claim and the timelines in which documentation must be submitted. Typically, health plans are instructed by law to initially request only the minimum information necessary to pay a claim.
The following Medicare and ASHA documents provide excellent guidance on documentation requirements:
Can I accept a payment from a health plan if the amount is higher than my usual and customary one?
A provider cannot charge Medicare a greater fee then their normal fee for a service, thus may not accept the higher fee. The Medicare payment will be the lower of the actual charge or the fee schedule allowance. If the reimbursement is from a private insurance company the speech-language pathologist or audiologist should refer to the contract between the provider and the health plan. If no such contract exists, the professional should contact the payer for clarification.