Crisis in Health Care Reimbursement Rising Costs, Dwindling Payments Hurt Patients and Clinicians Features
Features  |   September 01, 2006
Crisis in Health Care Reimbursement
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Practice Management / Features
Features   |   September 01, 2006
Crisis in Health Care Reimbursement
The ASHA Leader, September 2006, Vol. 11, 10-27. doi:10.1044/leader.FTR4.11122006.10
The ASHA Leader, September 2006, Vol. 11, 10-27. doi:10.1044/leader.FTR4.11122006.10
Reimbursement for health care services in the United States-including audiology and speech-language pathology services across all settings-is ailing. In this roundtable interview, veteran clinicians Dennis Burrows, an audiologist and ASHA’s Vice President for Quality of Service in Audiology, and Julie Noel, a speech-language pathologist and Speaker of the Legislative Council 2006, share their strong concerns about the current reimbursement climate with Managing Editor Marat Moore.
Leader: What situation are you facing now in terms of reimbursement for your services?
Burrows: As a nonprofit institution, we deal with a whole variety of issues-Medicaid in particular is not reimbursing even close to what our actual costs are, putting a burden on our practice. Medicaid reimbursement has not increased-in fact, it’s gone down in the 13 years that I’ve been here, but my costs continue to rise. We view serving Medicaid patients as part of our mission but it’s taking so much of our available monies for these services that we really aren’t able to continue to see Medicaid patients at the rate we’d like. It’s getting very difficult.
In audiology, we’re finding that third-party payers don’t always cover hearing aids or hearing services, and if they do it may be only in a physician’s office. So that’s problematic. And when they do cover hearing aids, they limit the patient to basic hearing aids or some type of discounted product, so we often have to write off a portion of that cost as well. However, with third-party payers we are able to balance-bill, so that is helpful if a person chooses not to go with a basic hearing aid, but to upgrade and pay the difference.
Noel: I am in a small private practice in Dallas with two other partners, and work primarily with children. We’ve noticed an increase in the denials of reimbursement for children with developmental delays. Our diagnostic codes are typically in the range of the 300 ICD-9 codes- 315.31 and 315.32, which deal primarily with receptive/expressive language disorders in children. Denials of those codes have increased, as well as the CPT codes that accompany those diagnostic codes.
We’ve also observed multiple requests for documentation. The process goes like this: You file your claim, they review it and typically send back a request for records, we provide those records multiple times. Then, maybe 60 days later, we’re told that those services have been denied. In the meantime, those clients still come to us and are still incurring charges, only to learn that those services will not be covered under their insurance plan.
It’s a domino effect-they deny on the code or accept the claim, review the claim, request documentation, then deny the claim-and all of that takes a great deal of time, and our reimbursement revenue stream is interrupted.
Leader: What changes have you seen in reimbursement in the past 5 or 10 years?
Burrows: What I’m finding in audiology is that some insurers are beginning to drop hearing services and hearing aids. Some are beginning to reduce their reimbursement amounts. Some are just making it more difficult to be reimbursed. I won’t go so far as to say it’s a strategy, but we have to jump through many more hoops to get paid. My data is very clear that the time to payment from the time of service has grown with third-party payers.
Noel: I would concur. The likelihood that insurers will not pay on certain codes has been steadily increasing. There continues to be this decreased reimbursement for services rendered by speech-language pathologists who treat children with developmental delays and for children who have genetic disorders such as Down syndrome.
We’ve also observed a continual increase in denial of claims with kids that have a physician’s order. Even with a physician’s order, even with tremendous documentation, even with valid assessment data to support our diagnosis that a child is presenting with a receptive/expressive language disorder, the insurance plan will not pay.
Families also are often told that their plan covers our services. But they don’t understand the ‘devil in the details.’ Families later learn that services are only covered for accident, illness, or injury, and that eliminates coverage for their children with developmental delays, which includes a large percentage of the kids who we see.
Leader: What is the impact on your clients and patients?
Burrows: Because of our increasing costs, we’ve had to limit how many Medicaid patients we see. In fact, we’re limiting the number very severely, at least now, because we’ve run out of money for the year. In terms of third-party payers, some have actually dropped benefits, and most of those patients won’t seek services. Among third-party payers that do pay, we’re seeing some folks who are opting to upgrade, because there’s such a stark difference in product available.
Noel: Our client base is mixed. We have some clients who are private-pay only. Being paid out of pocket is very nice, of course, because we are paid immediately after we render an invoice. But we also have a number of families who depend on reimbursement. On some plans, the number of visits you can have is capped. As the cost of delivering the services continues to rise, the amount of reimbursement is decreasing from third-party payers, and as a result families are not able to stay in our practice. We run a pretty lean machine, but we can’t provide services for free.
We’re at the mercy of the claims reviewer of the third-party payer, which in our case is the patient’s insurance plan. It’s really frustrating because quite frequently we’re put into the position of having to tell families that their insurance carrier has denied claims, so we’re looking to them-the patient-to pay the bill. Sometimes the claims denial appeal process takes several weeks or months, and sometimes we have to write off costs we can’t recover. It’s a very vicious cycle.
Leader: What will happen to your practice if this trend continues?
Burrows: Obviously we have to live within our means. So we’ll have to continue to limit access, which will have a huge impact on the community in terms of folks that will go without services, without the ability to hear. But I have seen a trend in audiology toward not accepting any third parties, including Medicaid. I don’t know if any data are out there, but anecdotally, as I’ve traveled and talked to people, I’ve heard that, more and more, people are doing a cash-only practice. Of course that serves a very particular segment of society.
Noel: I worked in the schools for a number of years, and then went into private practice, and Dennis is absolutely right. When you’re dealing with a population that wants to pay and can pay, that makes my life as a private practitioner much easier. I still deal with collections, but I don’t have to deal with this ongoing dialogue with the insurance companies trying to provide them materials over and over and over again. All of those costs add up.
When you end up spending more time with reimbursement issues than providing therapy, it makes you wonder: Am I in the right profession? Am I in the right job setting? What other options do I need to consider? Over time, for me, it would be one of the big reasons to look at other alternatives. I’m not at that point yet, though.
Burrows: There’s one thing I should add-because of reimbursement cuts and delays, my overhead costs have gone up. Now we have to get prior authorizations that we didn’t need before. One of the silliest things I’ve seen in audiology is that, on most insurance plans, we have to submit a bill to Medicare if the patient is Medicare-eligible. Then we wait to get a denial from Medicare, and submit to the insurance company. The insurers all know that Medicare doesn’t pay for hearing aids, but they require every patient to get the denial from Medicare. It’s a hoop we have to jump through. All those hoops add up. I used to have a half-time biller, but now I have a full-time billing person to help me jump through those hoops.
Leader: What in your view could be done to address these problems-on a federal, state, local, or professional level?
Burrows: For years, ASHA and AAA and local audiologists have worked on this, and I’ve talked to the state until I’ve turned blue. A few years ago I even submitted to the state a plan that would have saved them a million dollars in the hearing aid program for the state of Michigan. I testified before a Senate committee about that plan, and the need to cover hearing aids. And that went nowhere.
Whoever these people are-whether it’s the state or third-party insurers-it would help if they could be more collaborative with the provider. I understand the need to contain costs: I’m doing it in my practice. But to make it difficult for us to get paid when we are due payment is something that frustrates the heck out of me. To knock down those barriers would be very nice. To make it clear how we get paid would be nice, to not require ludicrous turndowns from Medicare. All those things help reduce my overhead.
I’m not sure that I’m in favor of the federal government getting into hearing aids, because any time the federal government gets into anything, it creates problems. I think the Hearing Aid Tax Credit and direct access legislation would help tremendously. Anything that can be done to make access to audiology easier and getting access to the funds that we’re owed would be a godsend.
Noel: I agree. ASHA’s doing a lot of wonderful things with its Focused Initiative on Health Care Reimbursement and the strategies that are in place. Also, in an ideal world, I’d like to find consistency across carriers when you file a claim, that a 315.31 that’s covered with Carrier A is covered by Carrier B and Carrier C. There seems to be no consistency across carriers, or across plans of the same carrier.
There are some SLPs in private practice who are very successful in working on contracts with multiple plans. They run a high-volume business, but they also have these issues with reimbursement and denials of payment. At a small private practice like ours, though, the problems are magnified. I would love it if we could identify just one private carrier as a model that does have a more consistent payment disbursement schedule, and maybe we could shop it to other groups. I don’t know what the answer is. We need to continue ramping up our coding efforts. But like Dennis, I don’t think the federal government needs to regulate how insurance plans cover certain codes for certain populations.
Maybe we need to work more closely with state insurance boards, to take a look how insurance is mandated for certain populations within a state. Texas mandates insurance coverage for speech and language services, and the code states that carriers cannot deny services for kids if the presenting problems are not due to accident, illness, or injury. But yet there’s a way for insurance companies to get around that and deny the coverage. That has to stop.
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September 2006
Volume 11, Issue 12