Frequently Asked Questions: H.R. 1116 - Medicare Audiology Services Enhancement Act of 2015

How does physician oversight change with H.R. 1116?

H.R. 1116 does not add an additional or new level of physician oversight. It does require audiologists to conform to Medicare requirements related to treatment services, which includes a plan of care that is standard practice for Medicare treatment services.  

Does H.R. 1116 require audiologists to have the plan of care approved by a physician before providing treatment and rehabilitative services to Medicare beneficiaries?

The plan of care is the standard for Medicare treatment services for all Medicare providers. It will be developed by the audiologist and must be reviewed and signed periodically by the physician. Current regulations allow all nonphysician providers 30 days of treatment before the plan of care must be signed. The plan of care ensures coordinated and integrated care among the treating professionals for the benefit of the patient. 

What is the impact of the bill on patient choice and access to audiology services?

Increasing patients' access to services is the primary goal of the bill. The bill allows for greater patient choice by allowing patients to seek the treatment services of an audiologist. Currently, the beneficiary has the choice of paying out-of-pocket for audiology treatment services when provided by the audiologist or seeking other providers, such as speech-language pathologists or physical therapists, to provide Medicare-covered auditory rehabilitation and balance therapy.

Is this bill consistent with the direction of health care?

Policy makers are looking for ways to manage costs while still providing quality services to Medicare beneficiaries. Private sector insurance providers are also looking for ways to cut costs and are developing their own bundled payments and utilization controls. For example, many insurance companies require a referral, and most require some sort of plan of care for all services, even those provided by a physician. This bill helps make audiologists part of the health care team. Being part of that team will be critical in the new payment models.

Does H.R. 1116 move audiologists away from autonomy?

Health care and Medicare are moving towards a medical/health home, accountable care organizations, and coordinated care 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.

Will the bill decrease access to services?

Currently, the requirement for providing covered audiological services to a Medicare beneficiaries includes an order from a physician or non-physician practitioner (i.e., 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 dispensing audiologists be required to unbundle their services?

Hearing aids and related services are not covered by the Medicare program. The decision decision to bundle or unbundle services related to the hearing aid rests with the dispensing audiologist.

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 of a plan of care. Because audiologists would remain under their own benefit category, the requirements for the plan of care may 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 (i.e., nurse practitioner, physician assistant or clinical nurse specialist).

Won't H.R. 1116 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. 1116 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 therapy cap, not expand it to more providers. The Medicare Audiology Services Enhancement Act of 2015 does not include amendments or references to therapy cap law and, in the absence of a law enacted by Congress, the Centers for Medicare & Medicaid Services (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. 1116 have the unintended consequence of reducing reimbursement levels for audiology services?

Most of the codes for the services covered under H.R. 1116 are already valued, including intraoperative monitoring and canalith repositioning. The bill will not trigger a revaluation of codes already in use by other health care professionals. 

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?

H.R. 1116 does not change current Medicare rules that allow the audiologist to (1) participate fully, (2) accept Medicare beneficiaries as a nonparticipating provider—which means the audiologist collects the Medicare fee from the beneficiary, who is paid directly by Medicare, or (3) not see any Medicare beneficiaries at all.

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 care 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, was 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 Medicare Audiology Services Enhancement Act of 2015 (H.R. 1116) was introduced by Representative Gus Bilirakis (R-FL), a member of the House, Energy and Commerce Committee; and Representative Butterfield (D-NC). 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 outcome measures associated with a diagnostic benefit when the person diagnosing the care is not responsible for treating the condition that was diagnosed. A Medicare 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 would 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 would 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 (i.e., nurse practitioner, physician assistant, or clinical nurse specialist) would 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 Medicare Audiology Services Enhancement Act of 2015 (H.R. 1116) allows Medicare to expand coverage of treatment services when performed by an audiologist. 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. Moreover, our legislative approach is consistent with the trend in health care where reimbursement is based on quality and patient outcomes through coordinated care.

When the Medicare regulations refer to certain professions that can "opt-out," what do they mean?

"Opting-out" means that physicians and a small number of other professions may choose to accept payment from the Medicare beneficiary, and the beneficiary or provider cannot bill Medicare for those services. The services are 100% paid out-of-pocket by the beneficiary. A provider who chooses to opt-out must enter into private contracts with all of his or her 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 fewer than 2% of providers who have the option to opt-out choose to use it. The bill does not include an opt-out provision for audiologists.

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 Medicare Audiology Services Enhancement Act of 2015, ask your member of Congress to cosponsor the bill.

ASHA Contact:
Ingrida Lusis
Director of Federal and Political Advocacy
E-mail: ilusis@asha.org

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