Expanding Medicare Audiology Coverage Comprehensive Medicare audiology coverage is a top priority on ASHA’s 2010 public policy agenda. Comprehensive coverage would move audiology from a diagnostic-only benefit to one that provides reimbursement for a full scope of audiologic services, including rehabilitative services performed by an audiologist. And although direct access also remains a top ... Policy Analysis
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Policy Analysis  |   February 01, 2010
Expanding Medicare Audiology Coverage
Author Notes
  • Ingrida Lusis, director of federal and political advocacy, can be reached at ilusis@asha.org.
    Ingrida Lusis, director of federal and political advocacy, can be reached at ilusis@asha.org.×
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Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   February 01, 2010
Expanding Medicare Audiology Coverage
The ASHA Leader, February 2010, Vol. 15, 1-8. doi:10.1044/leader.PA1.15022010.1
The ASHA Leader, February 2010, Vol. 15, 1-8. doi:10.1044/leader.PA1.15022010.1
Comprehensive Medicare audiology coverage is a top priority on ASHA’s 2010 public policy agenda. Comprehensive coverage would move audiology from a diagnostic-only benefit to one that provides reimbursement for a full scope of audiologic services, including rehabilitative services performed by an audiologist. And although direct access also remains a top priority, it better serves audiologists and consumers to pursue comprehensive coverage—which includes direct access.
For more than 10 years, audiology professionals have been striving for direct access—for Medicare beneficiaries to be able to seek services from audiologists without a physician’s referral. Other large health plans, including private coverage and the plan for military veterans, have this benefit. However, despite legislation introduced in the previous five congressional sessions, Medicare direct access for audiology has remained elusive.
Three factors are impeding the direct access effort, and ASHA’s strategic efforts in 2010 are designed to overcome these challenges.
Direct Access Challenges
The three significant barriers to legislative success include the policies and regulations of the Centers for Medicare and Medicaid Services (CMS), the agency that administers the Medicare program; physicians’ concerns that audiologists will not refer back if a medical condition is detected; and the fiscal impact of direct access on the Medicare Trust Fund. Each of these barriers must be addressed for any significant progress to take place.
CMS Policies and Regulations
There is no defined benefit for audiology services under Medicare. Instead, diagnostic services provided by an audiologist are part of the Medicare diagnostic benefit. Regulations implementing the diagnostic test benefit require that the tests be ordered by a treating physician, who will use the results in the management of the beneficiary’s specific medical problem.
Testing must be ordered for diagnostic purposes and to evaluate the need for appropriate medical or surgical treatment of a hearing loss or other medical problem. Rehabilitative services and diagnostic services related to the need for a hearing aid are not covered.
In addition, in a 2006 report to Congress, CMS said that the current policy is key to assuring that Medicare beneficiaries are receiving medically necessary services and serves as a mechanism for avoiding potential payment for asymptomatic screening tests that are not covered. According to CMS, without the referral requirement, Medicare cannot avoid payment for non-covered screening tests.
Physician Concerns
Physicians frequently argue that audiologists will not refer patients presenting with medical conditions to physicians. Although the federal Food and Drug Administration has regulations related to referrals to physicians by audiologists and most audiologists are bound by a code of ethics, physicians argue that no mechanisms exist to ensure compliance.
Fiscal Impact
There is no solid data on the cost/fiscal impact of direct access on the Medicare Trust Fund. It can be argued that direct access could save money because a beneficiary would not be required to first seek a physician’s services. Congress and budget analysts, however, do not necessarily share this view. CMS already has indicated that removing the referral requirement might result in non-covered services, such as screening for a hearing aid, being reimbursed inadvertently by Medicare.
Historically, the Congressional Budget Office has placed a high cost estimate on Medicare benefit changes that may increase usage (i.e., if the benefit is available, more providers will enroll in the program, and more beneficiaries will access the services). High-cost additions to the Medicare program require an offset of cost reductions in other areas of Medicare.
Finding the Solution
Each of these three roadblocks—CMS policies and regulations, physician concerns, and fiscal impact—must be addressed. Because of these barriers, ASHA believes that advocating for direct access alone may not be the best strategy. Instead, a more prudent legislative strategy would be to create a comprehensive audiology benefit under the Medicare program that would include both diagnostic and rehabilitative services. Soon ASHA will launch a legislative campaign to define a comprehensive audiology benefit to insert into Medicare law.
The restricted definition of audiology as only diagnostic, as it is now, is detrimental to the future of the profession. CMS views diagnostic services as technical procedures that do not require professional judgment. This perception that the work of an audiologist is technical (rather than professional) has resulted in a devaluation of some audiology procedures under Medicare and, consequently, lower reimbursement rates. Private health plans are likely to follow this trend.
One possible solution to address physicians’ concerns is to create a compliance mechanism through another CMS initiative. The Physician Quality Reporting Initiative (PQRI) offers an annual bonus to providers who report quality measures. Audiologists are eligible to participate in PQRI; in 2010, the first year of audiologists’ participation, CMS has adopted three measures related to the FDA regulations. These measures were developed by the Audiology Quality Consortium (AQC), an organization of audiology groups convened by ASHA to develop quality measures, and are designed to ensure that audiologists refer patients with medical conditions to physicians.
Data on the cost-effectiveness of services and improved beneficiary outcomes are essential in achieving a legislative victory. There is a critical need for research documenting the cost-benefit ratio of audiologic rehabilitative services on outcomes, especially in the Medicare population, to support legislative efforts for comprehensive coverage. The audiology clinical and research communities must work collaboratively to investigate the potential impact of and costs associated with a more comprehensive audiology benefit.
The fight for Medicare coverage of audiologic rehabilitative services will be long and difficult, and opposition is expected to continue. It’s a fight that is likely to last over several sessions of Congress; however, it’s a battle that cannot be ignored. Moreover, the importance of the audiology community working together to overcome these barriers to direct access and comprehensive coverage cannot be underestimated.
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February 2010
Volume 15, Issue 2