Should I Opt In or Opt Out?

TPAs with William Ranes and Dan Quall

Third-party payers (TPAs) and hearing aid benefit plans (HABPs) are reshaping the audiology industry. Nationwide, audiology and ENT practices are grappling with the critical decision of whether entering into contracts with TPAs is in their best interest. This Ask Fuel First article isn’t just about dry statistics or boilerplate advice. We dive deep to analyze the impact on your bottom line, patient care and professional autonomy by answering the following question: Should I opt in or opt out of TPA contracts?

William Ranes, Fuel Medical’s Taskforce Officer, had a chance to sit down with Dan Quall, Fuel Medical’s Director of Strategic Initiatives, to discuss the impact of TPAs on the audiology and ENT industry. Here are some of the highlights of that conversation.

The Evolution of Insurance Companies and TPAs

Insurance companies are evolving to attract patients by adding benefits, such as vision and hearing, gym memberships and more. But these companies don’t necessarily want to manage those plans. That’s where TPAs come in; they are the go-between the insurance company and the patient. There are two places that these companies (TPAs) have to operate very tightly in order to be profitable: 1) the type of hearing aids sold and the cost to purchase them, leaning towards lower costs on the TPA’s end and 2) the amount of money they can get reimbursed by the insurance company. Since nearly 70% of private practice revenue is from hearing aid sales, TPAs have a major impact. Because of this, we need to look at the margin per clinical hour. Dan emphasized that practices need to look closely at reimbursements in their contracts. Sometimes, reimbursement rates are fine, especially if the audiologist just spends a short time with patients. Other times, it doesn’t make financial sense. That’s when they need to decide if they should opt in or opt out of accepting TPA patients.

Deciding whether to opt in or opt out of accepting TPA contracts is partly based on who you are, your accounting preferences and the size of your business. We suggest you contact your regional team to find a customized solution to fit your individual needs—we can offer some recommendations based on the size of your practice.

While some HABPs (hearing aid benefit plans) can serve as a pipeline for new patients, understanding the terms of each HABP is critical to determine if you can afford to provide the level of care at the agreed-upon rates that the plan requires. 

Opting In

When you opt in, you need to pay close attention to growing your private-pay patient base by leaving scheduled blocks to work with new or existing patients. It’s important that your scheduling protocols allow you to get to your private-pay and physician-referral patients in a reasonable amount of time. Opting in also means that staff must be knowledgeable about HABPs. From your front office and billing staff to your providers, everyone needs to understand what is covered by patients’ insurance plans and what isn’t. You aren’t limited by the types of additional services you offer patients even when their plans won’t cover them, but patients need to be told of additional costs beforehand. This reduces your patients’ frustration and ensures you’re billing all services appropriately.

Above all else, remember that you can’t give away your services for free and expect to remain in business. This doesn’t mean you have to reduce your level of service. Instead, you need to be intentional about educating patients and asking them to pay for non-covered services. Using planned materials and talk tracks, staff training and good execution are essential when working with any patient, but even more so when you opt out.

Opting Out

Opting out allows your providers to be more influential in your patients’ hearing health journey. Patients always have the option not to partake of their benefits, but many feel limited in their choices because of policy restrictions. When they choose your practice, knowing that insurance benefits are not applicable, they’ll be open to alternatives, such as practice-specific service plans and Fuel Medical’s Access Hearing program. Ultimately, you have an opportunity to individualize patient care on a greater scale. Developing a solid strategy is key to keeping your patients’ hearing and your practice’s finances healthy.

As you weigh the pros and cons of opting in or opting out of HABP contracts, explore the intricacies of each with your Fuel Medical regional team. Whether you’ve chosen to embrace TPAs or not, it’s your path to forge. The best part is that you can reassess your decision periodically because staying flexible in this changing landscape preserves your practice’s success for the long term.

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