Audiology Unbundled Wake Forest Baptist Health restructured their audiology clinic to establish an unbundled services model. Here’s how they did it. All Ears on Audiology
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All Ears on Audiology  |   February 01, 2018
Audiology Unbundled
Author Notes
  • Meagan Lewis, AuD, is director of audiology in the Department of Otolaryngology Head and Neck Surgery at Wake Forest Baptist Health in Winston-Salem, North Carolina. melewis@wakehealth.edu
    Meagan Lewis, AuD, is director of audiology in the Department of Otolaryngology Head and Neck Surgery at Wake Forest Baptist Health in Winston-Salem, North Carolina. melewis@wakehealth.edu×
Article Information
Hearing Disorders / Hearing Aids, Cochlear Implants & Assistive Technology / All Ears on Audiology
All Ears on Audiology   |   February 01, 2018
Audiology Unbundled
The ASHA Leader, February 2018, Vol. 23, 22-23. doi:10.1044/leader.AEA.23022018.22
The ASHA Leader, February 2018, Vol. 23, 22-23. doi:10.1044/leader.AEA.23022018.22
This past year, legislation was introduced to eliminate medical waivers for hearing aids and allow the sale of over-the-counter devices.
The amalgamation of those and other factors led us to evaluate our service-provision model at Wake Forest Baptist and forced us to take a long, hard look at where we want to go as a clinic and as professionnals.
Ultimately, driven by our core belief in evidence-based practice, we decided to change our model of hearing aid consultations, fittings and follow-up. Instead of bundling all services into one price, we shifted to describing each procedure and charging for them separately. Here’s how we arrived at that decision and changed our approach.
The planning process
We started with a question. What differentiates us from our competitors in the hearing health care market?
We organized a task force (six of our 14 dispensing audiologists) to answer our original question. The consensus was that our hallmark is quality, but there were differing opinions on what constituted that “quality.”
Much conversation focused on which procedures should be performed at the hearing aid evaluation appointment to allow for a “best” recommendation. Other conversation focused on whether real-ear measures were necessary at the first appointment or a follow-up appointment, or both. We had an additional debate on the need for electroacoustic analysis before the hearing aid fitting.
We searched the literature for best practices in prescribing and fitting hearing aids and follow-up for our patients. After review and discussion of the literature, we revised our protocols to include electroacoustic analysis prior to fitting devices. We determined it was necessary to include subjective and objective measurements such as speech-in-noise testing, UCLs (uncomfortable loudness levels), and the COSI (Client-Oriented Scale of Improvement).
We also developed a business plan and new charge master (a list of all procedures and their pricing). In our large hospital setting, uncovering salary information, overhead and space rental took intensive investigation. Once we had data for benefits, salaries, equipment and space, we calculated our break-even. Using CPT (Current Procedural Terminology,® American Medical Association) codes for hearing aid fittings, we assigned pricing for each procedure based on the length of time needed to perform it.

We started with a question. What differentiates us from our competitors in the hearing health care market?

The ‘unbundled’ approach
Like most clinics, our services have traditionally been “bundled,” with no fee for consultation. There was one overall charge encompassing the hearing aid fitting and follow-ups for three years. The charge for the devices was, quite frankly, what we assumed would cover our time, including consultation. However, by not charging for the time, we felt this sent a message that the time is not worth an investment.
If a patient is not gaining information that leads to better hearing aid selection, then it likely isn’t valuable to them. In contrast, when data can drive expectations and recommendations, the service (the evaluation) has value.
In the new “unbundled” model, we agreed to charge for hearing aid evaluations. Our hearing aid recommendations are driven by assessments such as LDLS (loudness discomfort levels), Quick-SIN (speech-in-noise test), COSI and other patient-reported outcome inventories. It makes sense to charge for the evaluation because performing these assessments and interpreting results are a valuable service for patients who need hearing aids.
In our new unbundled model, the patient pays for the device and the first 45 days of itemized services. Services include the hearing aid evaluation, electroacoustic analysis, real-ear measures, check and clean, programming, orientation, and two additional programming sessions. Each of these services has an itemized CPT code. Patients then have the option to pay for services as they receive them or to purchase a bundled service package. The rationale behind this structure is to offer a lower up-front cost to patients to encourage them to return for fittings when appropriate.
To ensure smooth implementation of our unbundling, we trained our patient schedulers, physicians and audiologists to effectively communicate the changes to patients. We also practiced, conducting faux consultations with each other in which we explained the rationale behind the change (for existing patients) and the value of the services we provide.
We implemented our new pricing strategy on May 1, 2017.

Clinicians must remain flexible and educate patients about the science and method behind what we do.

Adaptive abilities
Some would say that our model isn’t truly “unbundled” because of the comprehensive nature of our hearing aid evaluation. Let me explain. My colleagues and I believe that procedures such as verification measures are vital to fitting a hearing aid. As a result, we provide an all-in-one evaluation and fitting protocol that includes these procedures. We then offer à la carte options for follow-up.
There is also the consideration of payers. Some allow individual CPT code billing, while others (and our biggest payer) specify that they will pay a total amount and it does not matter whether this is itemized or not. Legal advice was critical in developing this plan, as was an understanding of how medical center billing works.
As I am writing this, it has been six months since our “go-live” date. There have been many lessons. As you would expect, some patients did complain. For example, one long-time client felt she was being “nickled and dimed.” However, I pointed out that she only comes to the clinic once every six months to a year for cleaning of her seven-year-old hearing aids. She wanted to upgrade but was intimidated by the expense. In the itemized model, her initial costs are less and she can opt to pay for services as she receives them. She scheduled a hearing aid consult for the following week.
Another advantage has been improved flexibility for patients new to our clinic. If they were fitted by another audiologist or clinic, we can now charge for specific services more easily than our previous model allowed.
As of now, we have not seen a decline in number of consultations or devices fit. In fact, compared to the same time last year, the number of devices fit has increased. That does not mean that we haven’t had potential patients cancel their appointments when they discover that there is a charge, but we can customize our model based on patients’ needs.
For example, one patient’s insurance provider sends devices by mail. We charged the patient for the consultation, then had him bring in his mailed hearing aids so we could maximize the devices’ settings. Another patient decided that he wanted a PSAP after we conducted hearing-in-noise testing and discussed lifestyle issues with him. We verified the device and helped him with the settings.
Communication is key in an itemized model. Clinicians must remain flexible and educate patients about our science and methodology. Expertise and flexibility are both critical components in elevating our practices and audiology in a changing environment.
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February 2018
Volume 23, Issue 2