TECH Talk: Kali Markle, AuD, discusses how the Cochlear™ Mini Microphone 2+ can help your patients in the classroom and beyond

By: Kalisha Barrett

Health insurance policy change happens, but how? Patients, parents, advocacy organizations, professional organizations, state representatives, and manufactures all have a role in shaping insurance policy and driving change. Patients and parents who are willing to share their stories and explain the value of the implantable hearing technologies in their lives, call local legislators, and write letters can support policy change. Providers and professional societal organizations can share their clinical expertise and empower patients by educating them on how to address lack of insurance coverage. State Legislators work with patients, societal organizations, and providers to sponsor bills and push for legislation which impacts health insurance policies. Successful policy change is enacted with the help of all of these parties working together to change unfavorable insurance coverage.

Providers are often unclear about the level of commitment required for “payer advocacy.” However, successful policy change has been implemented time and time again, with the help of providers who help patients gain fair access to insurance coverage.

Providers who are involved in payer advocacy recommend staying involved in national organizations as well as their local and state professional organizations. In an effort to stay in tune with local legislative initiatives, providers can participate in the various committees within those professional organizations or on state appointed boards through Health and Human Services or state public health agencies. By staying involved in local professional organizations, providers also gain access to resources available to members.

Cochlear Americas understands the importance of assisting patients and providers with payer advocacy and navigating the health insurance landscape. We have a dedicated health economic and reimbursement department staffed with reimbursement managers and specialists to support payer advocacy. We know the challenges candidates face with accessing cochlear implants and hearing technologies.  Cochlear has put together a Quick Tips for Obtaining Insurance Coverage to offer some best practices providers can implement to help successfully maneuver through the insurance web.

Otologic Management Services (OMS) is another service available to provide support for candidates and healthcare providers seeking to obtain necessary insurance approval and to support appeals where coverage has been denied for Cochlear™ Nucleus® or Baha® Systems for medically qualified candidates. OMS can assist candidates and providers with obtaining an optional process called predetermination. This is the process that allows a provider to request services to determine coverage prior to surgery. The health plan will review the patient’s health benefits and medical policies to determine if the treatment will be covered.

OMS Contact Information

Phone: (800) 633-4667 option 4

Email: OMS@Cochlear.com

For the latest information, visit www.Cochlear.com/US/Professionals and click on Resources-Reimbursement Solutions-Coding and Billing Support for Professionals/Facilities or call the Cochlear Coding Support Hotline at (800) 587-6910.

About our guest author:

Kalisha Barrett is the Health Policy Manager on Cochlear Americas Health Economics and Reimbursement Strategies team. In her role, she assists with executing strategies aimed at expanding patient access to hearing implants and related services through both state and national advocacy efforts. Additional reimbursement support offered by Cochlear’s Regional Reimbursement team can be found on the Reimbursement Support page of Cochlear’s US Professional Resources Website. Please do not hesitate to reach out to Kalisha or the Regional Reimbursement Manager associated with your geography for reimbursement assistance or for questions related to this article. Cochlear offers coding assistance through the Coding Support Line accessible by calling 1-800-587-6910 between the hours of 8 AM – 3 PM Mountain Standard time zone or via email at codingsupport@cochlear.com. For pre-surgical insurance support, OMS is available to assist with pre-authorizations and appeals and can be reached at 1-800-633-4667 option 4.

By guest author: Keith Latiolais, MBA, MHA

On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released their annual changes to the Medicare Physician Fee Schedule (PFS) and other Medicare Part B payment policies. Proposed rule CMS–1693–P includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019. The rule was published on July 27, 2018 and is available for public comments through September 10, 2018.

CMS proposed increasing Physician Fee Schedule (PFS) payment rates by 0.25 percent in 2019, as required by the Medicare Access and CHIP Reauthorization Act. After applying the budget-neutrality adjustment which is required by law, CMS estimates the 2019 physician fee schedule conversion factor to increase from $35.99 this year to $36.05 in 2019. CMS included a number of other provisions in the rule including revaluation of outdated E/M code set to address complexity of documentation requirements, distinguish differences among code levels and sites of service, update for changes in technology, especially electronic health record (EHR) use, and physician pay for virtual and telephone visits.  Details are available on the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1693-P.html  see section I. Evaluation & Management (E/M) Visits.

CMS is proposing implementation of these rules beginning January 1, 2019, but is sensitive to stakeholder comments and as such may consider a delayed implementation which also might allow the AMA time to develop changes to the CPT coding definitions and guidance prior to implementation.  To be assured consideration, comments must be received no later than 5 p.m. on September 10, 2018.  In commenting, please refer to file code CMS-1693-P.  Electronically, commenters may submit to http:www.regulations.gov or by regular mail to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1693-P, P.O. Box 8016, Baltimore, MD 21244-8016.

The following is a summary of the impact of the proposed changes specific to professional services related to cochlear implants and auditory osseointegrated implants. The tables below illustrate the difference between the geographically unadjusted participating surgeon and audiologist rates for the current year and those which have been proposed for CY 2019. The last table includes the Medicare allowable rates for facility based audiologist.

Note:  Physician payment for services performed in the facility setting (as well as in the office) is calculated using national uniform relative value units (RVUs) that account for relative resources used in furnishing a service.  The statute requires that RVUs be established for three categories of resources: Work, Practice Expense (PE), and Malpractice (MP).  Beginning in CY2010 with final implementation in CY2013 CMS began using the AMA Physician Practice Expense Information Survey (PPIS) to establish a methodology for Practice Expense RVU calculations.  Analysis of 2019 CI implantation codes indicates a reduction in overall RVU, hence reimbursement, primarily due to a re-evaluation of Practice Expense RVU methodology.

Payments are based on the relative resources typically used to furnish the service. Relative Value Units (RVUs) are applied to each service for physician work, practice expense, and malpractice. These RVUs become payment rates through the application of a conversion factor. Payment rates are calculated to include an overall payment update specified by statute. 

About our guest author:

Keith Latiolais is one of three geographically-based hearing implant reimbursement experts available to assist you with coding, payment, payer coverage, contracting, and other reimbursement-related challenges. Keith’s contact information, along with that of his colleagues and a more detailed description of the reimbursement support offered by Cochlear’s Regional Reimbursement team, can be found on the Reimbursement Support page of Cochlear’s US Professional Resources Website. Please do not hesitate to reach out to the Reimbursement Manager associated with your geography for reimbursement assistance or for questions related to this article. Cochlear offers coding assistance through the Coding Support Line accessible by calling 1-800-587-6910 between the hours of 8 AM – 3 PM Mountain time zone or via email at codingsupport@cochlear.com. For pre-surgical insurance support, OMS is available to assist with pre-authorizations and appeals and can be reached at 1-800-633-4667 option 4.

References:

1. Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019,  Retrieved from:  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12-2.html   August 2, 2019

Health economics and reimbursement information provided by Cochlear Americas is gathered from CMS and other third-party sources. The information is subject to change without notice as a result of changes to laws, regulations, rules and administrative policies. CPT and CPT material are copyrights of American Medical Association (AMA): CPT copyright 2018 American Medical Association, all rights reserved. CPT is a registered trademark of the American Medical Association. The information provided in this document is provided as guidelines only to address the unique nature of implantable hearing solutions technology. This information does not constitute reimbursement or legal advice. Cochlear Americas makes no representation or warranty regarding this information or its completeness, accuracy, fitness for any purpose, timeliness, or that following these guidelines will result in any form of coverage or reimbursement from any insurance company or federal health care program payer. The information presented herein is subject to change at any time. This information cannot and does not contemplate all situations that a health care professional may encounter. To be sure that you have the most current and applicable information available for your unique circumstances, please consult your own experts and seek your own legal advice regarding your reimbursement and coding needs and the proper implementation of these guidelines. All products should be used according to their labeling. In all cases, services billed must be medically necessary, actually performed, and appropriately documented in the medical record.