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Penny-wise and pound foolish: Top considerations when purchasing hearing technology Stephanie J. Sjoblad, Au.D. Clinic Coordinator / Associate Professor UNC Division of Speech and Hearing Barbara L. Winslow Warren, Au.D. Coordinator of Clinical Education / Assistant Professor UNC Division of Speech and Hearing Agenda Overview of Trends History of Hearing Healthcare Terms & Definitions American Academy of Audiology Hearing Aid Billing Practices Survey Results A Model for Unbundling Current Trends vs. Best Practice Image: http://www.propwise.sg/are-you-being-pennywise-pound-foolish/ Audiologist Consumer Professor Advocate Mommy, Wife, Daughter, Sister, Friend And one more…Bargain hunter! Clinical Coordinator Show of hands…who has ever…. GONE TO A YARD SALE SHOPPED AT A THRIFT STORE BOUGHT SOMETHING AT A CONSIGNMENT SHOP PERUSED CRAIGSLIST EXPERIENCED THE THRILL OF WINNING AN EBAY AUCTION Have you thought about saving money on hearing healthcare…. ONLINE HEARING TESTS INTERNET HEARING AID PURCHASES BIG BOX/WAREHOUSE HEARING AID PURCHASES 30+ years of marketing the product! “The price of your X hearing aid includes custom programming if you so desire. Your hearing aid is already programmed for high frequency hearing loss - the most common hearing loss curves in the hard-ofhearing population.” The History of Our Profession It was an ASHA Code of Ethics violation for audiologists to dispense hearing aids. The audiologist recommended the device(s) and the patient purchased the device as a retail product from a distributor. Audiologists were paid for their services, including: diagnostic services, administering hearing aid evaluations, and hearing aid adjustments and audiologic rehab. The Supreme Court ruled that “A society’s canon of ethics having the effect of limiting compensation among the society’s members is illegal.” Handbook of Clinical Audiology, 5th Edition Katz, Burkard, Medvetsky, 2002 Understanding Economies of Scale Hearing Aids Cell phones Only 2% of our population use hearing aids 10 Economics of volume purchases Veteran’s Administration BIG BOX STORES Sole Provider Hearing aids do not magically just work Hearing Aids 5/29/2012 Professional Services Maximum Communication Improvement 12 Hearing well in a noisy world, Consumer Reports (2009) • • • • • • Sound-proof booth for testing Several types of hearing tests Choice of brands, styles and features Real Ear Measures to customize the fitting Rehab classes and/or therapy Flexible evaluation period with option to return hearing aid(s) • Convenient hours • Walk-in repairs Find a licensed and certified audiologist that offers the above AND an unbundled pricing option. Bundled Billing Combining products & services into one lump sum. PATIENT’S BILL Hearing Aid Hearing Aid Pre-Fitting EAA Fitting 2 Years Pre-Fitting D-Mic Test Fee of Service Real-Ear Measures $ Bundled Billing Combining products & services into one lump sum. PATIENT’S BILL 2 wk: Follow-up 4 wk: Follow-up $ 6 wk: Follow-up 6 mo: Tubing Change 12 mo: Annual Check 15 mo: Repair (wax) 17 mo: Tubing Change 20 mo: Repair (Moisture) 24 mo: Annual Check Unbundled Billing Breaking up prices completely. PATIENT’S BILL Hearing Aid Hearing Aid Pre-Fitting EAA Pre-Fitting D-Mic 2-Years Test Fitting Service Fee Real-Ear Measures $ $ $ $ Unbundled Billing Breaking up prices completely. PATIENT’S BILL 2 wk: Follow-up Hearing 4 wk: Follow-up Aid 6 wk: Follow-up $ $ $ $ Hearing Aid 6 mo: Tubing Change 12 mo: Annual Check Pre-Fitting D-Mic Test 15 mo: Repair (wax) 17 mo: Tubing Change Real Ear Measurements 20 mo: Repair (Moisture) 24 mo: Annual Check Completely Unbundled Billing Advantages: Disadvantages: • Transparency • More options for patients • Defers much of the cost until services are rendered • Patient pays only for what is used • Could meet patient’s needs easily • Patients may wish to eliminate necessary procedures (EAA, REM, etc.) • Patients may not reliably return for necessary visits because they will need to pay • May increase administrative time to manage • Greater possibility of not collecting billables AAA Hearing Aid Billing Practices Survey Does your clinic bundle services into the price of hearing aids? 2011 2012 No 20% No 33% Yes 67% Yes 80% A survey in 2006 reported that 87% of hearing aid dispensers are bundling. (Hearing Journal, 2006) 2012 AAA Hearing Aid Billing Practices Survey Does your clinic retain a non-refundable professional fee if the hearing aid(s) are returned for credit? State Laws require that all fees incurred with the provision of a hearing aid be returned 7% No 16% Yes 77% State Law requires that all fees be returned to the patient. 6% 2011 No 18% Yes 76% 2012 AAA Hearing Aid Billing Practices Survey Is the non-refundable fitting and professional fee… 72.6% 11.4% 6.5% 1.8% Contingent on the services provided 6.1% 1.6% A flat rate regardless A flat rate based on A percentage of the Cannot charge a fee as of hearing aid the level of technology total cost of the this would violate technology/style/price hearing aid state law(s) Other Professional Services are valuable DENTISTS OPTOMETRISTS HAIR STYLISTS PLUMBERS ETC… UNC- Hearing & Communication Center 11 years ago – an inspiring conversation He wanted to pay for services after a one hour visit Dr. B, a retired dentist from the UNC School of Dentistry •His hearing aids were over 2 years old •His warranty had expired At the time, we were charging NOTHING We arbitrarily chose an hourly rate for services Began charging small amounts for services such as tubing changes, inhouse repairs, etc. 2005 A new beginning at UNC-HCC Mission: To make hearing care more affordable! • Lowered hearing aid prices, as 2 years of services were no longer included up-front » Included a 60-day “trial” period • Term “Trial Period” became “Evaluation & Adjustment Period” • Non-refundable professional fee increased proportionately to reflect services rendered during E&A Period. » Included: • Pre-fitting Electroacoustic Analysis (EAA) • Real-Ear Measurements (REM) • Follow-up and Adjustments for 60 days • Our model was inspired by Patricia Gans. (J. Nemes, “To bundle or not to bundle? That is the question.”Hearing Journal, April 2004.) Our [Partially] Unbundled Billing up prices completely, Breaking upBreaking prices completely, after the TRIAL period. after the EVALUATION AND ADJUSTMENT period. PATIENT’S BILL Hearing Aid Hearing Aid $ $ Pre-Fitting D-Mic Test 2-Years Pre-FittingProfessional EAA Checks Fee + Service 45 Days of Follow-Up Real-Ear Measures $ Our [Partially] Unbundled Billing Breaking up prices completely, after the initial evaluation and adjustment period. PATIENT’S BILL $ Hearing Aid $ $ Hearing Aid 2 wk: Follow-up 4 wk: Follow-up 6 wk: Follow-up 6 mo: Tubing Change 12 mo: Annual Check 15 mo: Repair (wax) $1000 Professional$3000 Fee + 17 mo: Tubing Change Fitting 2-Years 45 Days of Follow-Up Fee Service 20 mo: Repair (moisture) 24 mo: Annual Check Sample Impact on HA Prices: 2 Hearing Aids (premium tier, digital) Non-refundable professional fee Service period included, following fitting TOTAL INVESTMENT 2004 BUNDLED 2005 UNBUNDLED $5000 $X,XXX per device $200 total $XXX per ear Duration of manufacturer warranty $5200 60 days Lower upfront cost Enlightening patients …who purchased their hearing aids on or after July 1, 2005 or had never seen the unbundled model before. Mr. Smith, we are recommending XYZ hearing aids as a part of your treatment plan. The hearing aid cost is $X,XXX per device. We recommend 2 hearing aids, therefore the hearing aids will cost $X,XXX. The professional service fees to fit these hearing aids and for 45 days of services will be $XXX/ear. The professional service fees are non-refundable. Your total investment the day you go home with the hearing aids will be $X,XXX. Services after the 45 day evaluation and adjustment period will be fee for service. Image from: http://thefamouslastword.blogspot.com/2012/01/googlethinks-im-old-man.html Reassuring patients …who purchased their hearing aids prior to July 1, 2005. (And heard that their friends bought hearing aids yesterday, for less $.) Mrs. Jones – All the services you need during your 2 year manufacturer’s warranty period were paid for up front. You can come see us anytime you need services for your hearing aids and you have already paid for those visits. Our current policy no longer provides these unlimited services up front, and that is why the fee is less. Image from: http://interestingni.blogspot.com/2011/01/navyshocked-by-shipboard-profanity.html 5/29/2012 UNC-HCC Treatment Plan We do not ‘sell’ hearing aids. We aim to rehabilitate our patient’s hearing utilizing evidence-based clinical practice. As a part of our customized process, we encourage each patient to: • Participate in Better Hearing Workshops (Aural Rehabilitation) • Complete Auditory Training program - Listening And Communication Enhancement, also called “LACE” • Assess benefit and satisfaction throughout the process » Abbreviated Profile of Hearing Aid Benefit (APHAB) » Client Oriented Scale of Improvement (COSI) » Satisfaction with Amplification in Daily Life (SADL) The product is worthless if the patient cannot use it effectively. 36 Current Trends and Recommended Procedures What exactly is best practice in the hearing aid world? Current Trends: 5/29/2012 38 An Evidence-based Model Hearing Evaluation 5/29/2012 Functional Communication Assessment Hearing Aid Fitting Hearing Aid Followup Individualized and Group Aural Rehab 39 Current Trend: Online Hearing Tests Hearing Evaluation • Comprehensive Evaluation (92557) » Diagnosing the type and degree of hearing loss: • Extensive case history • Visual inspection / Otoscopy • Speech testing • Pure tone threshold search » Air conduction and bone conduction • Tympanometry (92567) • Acoustic reflexes (92550) 5/29/2012 41 Current Trend: Online Hearing Aid (HA) Purchases 63 options Hearing Aid Selection Hearing Aid Evaluation (92590/1) UNC HCC Functional Communication Assessment • Characteristics of Amplification Tool (COAT) • • • • Quick SIN (Speech in Noise) Loudness Discomfort Measures (LDL) Acceptable Noise Level (ANL) as needed Cochlear dead region testing (TEN-HL) as needed • Lifestyle Assessment • Client Oriented Scale of Improvement • HA selection • Earmold Impressions 44 5/29/2012 (R. Sweetow, “Instead of a hearing aid evaluation, let’s assess functional communication ability”. Hearing Journal, 2007.) Hearing Aid Selection Process Look for a clinic that offers an objective Hearing Aid Selection Process (92590, 92591 or V5010) “Functional Communication Assessment” (FCA) • Lifestyle Assessment • Self-Assessment Questionnaires (APHAB, COSI, COAT) • Loudness Discomfort Levels (LDL) Test • Quick Speech In Noise (QuickSIN) Test • Acceptable Noise Level (ANL) Test • Earmold Impressions Sweetow, R. (2007) Instead of a hearing aid evaluation, let’s assess functional communication ability. Hearing Journal, 60(9), 26-31. Current Trend: Wholesale/Online Hearing Aid Purchases Wholesale Store Audiology Clinic Ebay Hearing Aid Fitting Procedures • When the HAs are Received from the Manufacturer » Quality Assurance (V5011) • EAA, DM, HAC • The day of the Fitting » Conformity Evaluation (V5020) • Probe Microphone Measures » Hearing Aid Programming (V5014) » Orientation (V5011) • Care, maintenance, use » Dispensing Fee binaural (V5160) » Hearing Aid – digital BTE binaural (V5261) • Hearing aid fitting follow-up » Appointments included for 45 days 5/29/2012 • Recommend: 2 week and 4 week (six week as needed) 47 HA Quality Assurance Procedures • Behind the scenes (before patient arrives): » » » » Electroacoustic Analysis (EAA) Directional Microphone (DM) test Distortion test Hearing aid check • Visual inspection and listening check 5/29/2012 48 2008 – 2009: New Hearing Aids 12% Passed inspection/EAA Failed inspection/EAA 88% New Orders Failing QA Inspection by Manufacturer Manufacturer A Manufacturer B Manufacturer C 7.60% 20% 25% (S. Sjoblad, B. Warren. 2009.) 2008 – 2009: Repaired Hearing Aids 18% Passed inspection/EAA Failed inspection/EAA 82% Percentage of Repaired HAs Failing QA Measures Manufacturer A Manufacturer B Manufacturer C Manufacturer D Manufacturer E Manufacturer F 9.70% 18.90% 20.50% 41.20% 20% 0% (S. Sjoblad, B. Warren. 2009.) Hearing Aid Fitting • Day of Fitting » Conformity Evaluation (V5020) • Probe Microphone Measures/Real Ear Measures » Hearing Aid Programming (V5014) » Orientation (V5011) • Care, maintenance, use 5/29/2012 51 Real Ear Verification 5/29/2012 52 A Case for Real-Ear Measurements Pt’s Loudness Discomfort Levels Hearing Aid MPO 65 dB Speech 55 dB Speech Patient’s Hearing Thresholds (dBSPL) A Case for Real-Ear Measurements Pt’s Loudness Discomfort Levels Hearing Aid MPO 65 dB Speech 55 dB Speech Patient’s Hearing Thresholds (dBSPL) Hearing Aid Fitting Procedures • When the HAs are Received from the Manufacturer » Quality Assurance (V5011) • EAA, DM, HAC • The day of the Fitting » Conformity Evaluation (V5020) • Probe Microphone Measures » Hearing Aid Programming (V5014) » Orientation (V5011) • Care, maintenance, use » Dispensing Fee binaural (V5160) » Hearing Aid – digital BTE binaural (V5261) • Hearing aid fitting follow-up » Appointments included for 45 days 5/29/2012 • Recommend: 2 week and 4 week (six week as needed) 55 Balancing the Investment 5/29/2012 56 Current Trend: Ignoring the importance of HA follow‐up Hearing Aid Check: • Six Months: HEARING AID PROCEDURES, EARMOLDS, AND ACCESSORIES (and related professional services) √ CPT / HCPCS mod. DESCRIPTION FEE √ HCPCS mod. DESCRIPTION FEE √ √ V5257 V5299 Office Visit Digital BTE, monaural 92592 HA Check, monaural (visual & listening inspections) V5256 Digital ITE, monaural 92593 HA Check, binaural (visual & listening inspections) V5255 Digital ITC, monaural 92594 Electroacoustic Analysis, monaural V5254 Digital CIC, monaural 92595 Electroacoustic Analysis, binaural V5262 Disposable Aid, monaural V5014 HA Repair by Mfctr., 6 mo. Warranty V5261 Digital BTE, binaural V5014 HA Repair by Mfctr., 12 mo. Warranty V5260 Digital ITE, binaural V5014 HA Repair, in-house per ear small parts replaced V5259 Digital ITC, binaural V5014 HA Repair no charge V5259 Digital CIC, binaural V5267 HA Supplies/Accessories (see reverse) V5263 Disposable Aid, binaural 92590 HA Evaluation, monaural (Func. Comm. Assess.) V5241 Dispensing Fee, monaural 92591 HA Evaluation, binaural (Func. Comm. Assess.) V5160 Dispensing Fee, binaural V5275 Earmold Impression (each) V5110 Dispensing Fee, bilateral V5264 Earmold Custom (each) V5090 Dispensing Fee, unspecified aid (FM) V5265 Earmold, Disposable (each) V5200 Dispensing Fee, CROS V5011 Fitting and Orientation of Hearing Aid(s) V5240 Dispensing Fee, BICROS V5011 Fitting and Orientation of FM V5298 Hearing Aid, miscellaneous V5020 Conformity Evaluation (Real-Ear Measures) V5298 Lyric Subscription V5014 Hearing Aid Reprogramming 92630 Audiological Rehabilitation [pre-lingual] V5267 Musician's Earplugs Filters (each) 92633 Audiological Rehabilitation [post-lingual] » Office visit (V5299) » HAC (92592/3) • Visual and listening inspection » x2 Hearing aid repair, in house (V5014) • per ear – small parts replacement • Annual: » Office visit (V5299) » HAC (92592/3) • Visual and listening inspection » Hearing aid repair, in house (V5014) HCPCS mod. DESCRIPTION FEE 98960 Education & Training, individual 98961 Education & Training, 2-4 persons 98962 Education & Training,5-8 persons V7212 Encounter for hearing conservation & Tx 99002 Shipping and Handling V5299 Loss and Damage Deductible, per device V5299 HA Extended Warranty 69210 Cerumen Removal [IMPACTED] 92700 Cerumen Removal [not impacted] 98986 Telephone Assessment 98969 Online Assessment V5266 Battery (6 batteries/pk) V5266 Battery Club Membership (8pk of 6) V5268 ALD, Telephone V5269 ALD, Alerting V5270 ALD,TV Amplifier V5274 ALD, miscellaneous (ex. FM, wireless) V5299 Hearing Service Miscellaneous (Home visit) EAA at one year and as needed • per ear – small parts replacement » EAA and Directional Microphone testing (92594/5) 5/29/2012 58 Current Trend: Fear of Being Billed for Services HEARING AID PROCEDURES, EARMOLDS, AND ACCESSORIES (and related professional services) √ CPT / HCPCS mod. DESCRIPTION FEE √ HCPCS mod. DESCRIPTION FEE √ √ V5257 V5299 Office Visit Digital BTE, monaural 92592 HA Check, monaural (visual & listening inspections) V5256 Digital ITE, monaural 92593 HA Check, binaural (visual & listening inspections) V5255 Digital ITC, monaural 92594 Electroacoustic Analysis, monaural V5254 Digital CIC, monaural 92595 Electroacoustic Analysis, binaural V5262 Disposable Aid, monaural V5014 HA Repair by Mfctr., 6 mo. Warranty V5261 Digital BTE, binaural V5014 HA Repair by Mfctr., 12 mo. Warranty V5260 Digital ITE, binaural V5014 HA Repair, in-house per ear small parts replaced V5259 Digital ITC, binaural V5014 HA Repair no charge V5259 Digital CIC, binaural V5267 HA Supplies/Accessories (see reverse) V5263 Disposable Aid, binaural 92590 HA Evaluation, monaural (Func. Comm. Assess.) V5241 Dispensing Fee, monaural 92591 HA Evaluation, binaural (Func. Comm. Assess.) V5160 Dispensing Fee, binaural V5275 Earmold Impression (each) V5110 Dispensing Fee, bilateral V5264 Earmold Custom (each) V5090 Dispensing Fee, unspecified aid (FM) V5265 Earmold, Disposable (each) V5200 Dispensing Fee, CROS V5011 Fitting and Orientation of Hearing Aid(s) V5240 Dispensing Fee, BICROS V5011 Fitting and Orientation of FM V5298 Hearing Aid, miscellaneous V5020 Conformity Evaluation (Real-Ear Measures) V5298 Lyric Subscription V5014 Hearing Aid Reprogramming 92630 Audiological Rehabilitation [pre-lingual] V5267 Musician's Earplugs Filters (each) 92633 Audiological Rehabilitation [post-lingual] HCPCS mod. DESCRIPTION FEE 98960 Education & Training, individual 98961 Education & Training, 2-4 persons 98962 Education & Training,5-8 persons V7212 Encounter for hearing conservation & Tx 99002 Shipping and Handling V5299 Loss and Damage Deductible, per device V5299 HA Extended Warranty 69210 Cerumen Removal [IMPACTED] 92700 Cerumen Removal [not impacted] 98986 Telephone Assessment 98969 Online Assessment V5266 Battery (6 batteries/pk) V5266 Battery Club Membership (8pk of 6) V5268 ALD, Telephone V5269 ALD, Alerting V5270 ALD,TV Amplifier V5274 ALD, miscellaneous (ex. FM, wireless) V5299 Hearing Service Miscellaneous (Home visit) Insert graphics and info on online HE… x2 2011 Hearing Aid Billing Practices Survey How many visits does the average patient have during the “manufacturer’s warranty” period? Greater than 6 times annually 1.7% 5-6 times annually 4.4% 39.5% 3-4 times annually 54.3% 1-2 times annually 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% Why are there fees for repairs? Out of Warranty repair Patient pays the manufacturer’s repair invoice, plus a fee for our services. In Warranty Repair Patient still pays a fee for our services. SERVICES may include: • Hearing Aid Check -92592, 92593 • Attempt to repair the hearing aid in house - V5014 • EAA – 92594/5 • Directional Mic Test – 92594/5 • Hearing Aid Programming – V5014 • Feedback Test, as needed – V5014 • Synchronization, as needed – V5014 • Shipping and Handling– 99002 Includes most necessary services, standard accessories, semi-annual checkups, annual evaluation, etc. Premium Care Patient pays for services following trial/adjustment period Standard Care Minimal Care Service Plan Examples: “Worry Free Option” includes everything with VIP treatment for the life of the device. Coverstone, J. (2011) Fee for service models in audiology practices. Audiology Today, 24(5), 36-46. What our patients are saying? PATIENT: R.P. “I am more than happy to come in for any appointment that will improve my ability to hear and I am happy to pay for it.” PATIENT: S.M. “When it came time to fit my hearing aids, I really think your use of this thing [patient points to real‐ear measurement system] made all the difference.” “Yeah, [your billing method] did surprise me a little bit. But I think the main thing was that I was seeing everything that you guys do here, versus what I had been getting before.” PATIENT: S.H. “You are not charging me enough for all that you do.” PATIENT: S.O. “My experience with your clinic and these hearing aids is like nothing I have ever experienced before, I am so sorry I did not find you sooner.” Summary of Objectives Describe the considerations consumers should identify when embarking in the search for a hearing healthcare provider and new hearing technology. Understand various billing models and fee structures one may encounter during the hearing aid selection and evaluation process. Discuss the importance of evidence-based practice in successful hearing aid fitting and audiologic rehabilitation outcomes 5/29/2012 64 Finding the best hearing care checklist Find a Board Certified Audiologist who follows AAA Guidelines for Management of Hearing Loss Inquire if the practice offers itemized/unbundled billing options before you make an appointment Review the practice website and verify the use of objective hearing aid selection procedures and Real Ear Probe Microphone Measures Recognize that hearing aids will not cure hearing loss. Enroll in Audiologic Rehab classes and consider Auditory Training. Beyond Monday Morning… Be prepared that hearing loss treatment is an on-going process. Routinely attend your local HLAA Chapter meetings for ongoing support from others with hearing loss. Continue to educate yourself! 5/29/2012 66 Don’t be fooled by the mad world of hearing aid advertising. Image from: http://www.thefiscaltimes.com/Media/Slideshow/2012/03/21/Mad‐Men‐Advertising‐That‐Would‐Change‐America.aspx Proceed as a wise consumer! References • Bonta, R., (2004) Communicating true value. Advance for Audiologists, 6(5), 30-33 • Cavitt, K., (2010) Personal email communication. • Foltner, K., (2009) What’s my time worth? Part 3: Breakeven analysis. Advance for Audiologists, 11(3), 44. • Gitles, T., (1999), Re-inventing the profession: A new model of hearing care delivery (First of two parts). Hearing Journal, 52(9), 32-34. • Gitles, T., (1999) Re-inventing the profession: A new model of hearing care delivery (Second of two parts). Hearing Journal, 52(10), 53-55. 5/29/2012 68 References (con’t) • Nemes, J., (2004) To bundle or not to bundle? That is the question. Hearing Journal, 57(4), 19-24. • Stone, C., (2005) Real talk on unbundling. Advance for Audiologists, 7(6), 59-60, 76. • Sjoblad, S., Warren, B., (2009) Get real: Can QA checks and REM improve the bottom-line? Presented at AudiologyNow 2009, Dallas, Texas • Sweetow, R. (2007) Instead of a hearing aid evaluation, let’s assess functional communication ability. Hearing Journal, 60(9), 26-31. • Sweetow, R. (2009) Hearing aid delivery models: Part 1 of 2. Audiology Today, 21(5), 49 -57. 5/29/2012 69 References (con’t) • Sweetow, R. (2009) Hearing aid delivery models: Part 2 of 2. Audiology Today, 21(6), 33-37. • Van Vliet, D. (2003) In praise of unbundling. Hearing Journal, 56(4), 36. 5/29/2012 70 CONTACT INFORMATION: Stephanie Sjoblad: [email protected] Barbara Winslow Warren: [email protected] 5/29/2012 SPECIAL THANKS TO: AAA Debbie Abel, Au.D. Annette Burton, Au.D. Kim Cavitt, Au.D. Katherine Cresante Melissa Uhlman, Au.D 71