TPAs with William Ranes and Dan Quall
As a hearing professional, you should know that understanding the impact third-party payers (TPAs) can have on your business is no longer optional. It’s essential that you’re able to navigate the financial realities of hearing health care to remain profitable. In today’s market, one in five patients get their hearing aids through a Medicare Advantage plan administered by a TPA, and this number is expected to grow as the baby-boomer generation ages into Medicare eligibility. With this much of the market going through TPAs, Ask Fuel First answers the following question: Why should I be concerned about TPAs?
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.
Hearing Aid Delivery Channels
When Dan Quall, Fuel Medical’s Director of Strategic Initiatives, first started fitting hearing aids in the 1980s, patients often had to pay for hearing aids out-of-pocket. They would often say, “If only we had insurance that paid for hearing aids.” Now it’s 2024, and hearing aid benefits are often included in insurance policies, but it’s more complex than we ever expected.
There are five primary channels of how hearing aids are delivered to patients:
- Veterans Administration (VA): About 18% of hearing aids (about one out of five) are fitted through the VA.
- Retail: Almost 25% of hearing aids (about one out of four) are purchased through retail channels; Costco has about 18% of that market by itself.
- Managed Care Through TPAs: Well over 20% of hearing aids are fitted through plans managed by TPAs.
- Independent: About 30% of products go through private clinics (often associated with private-pay patients), which is slightly less than previously reported.
- Other: About 3% of hearing aids are fitted through other channels.
We’ve noticed a shift in delivery channels. Fewer patients are getting their hearing aids through private practices, or the independent channel, in favor of retail and managed care channels. The increase in retail sales wasn’t a huge surprise as over-the-counter devices were recently approved by the FDA. Interestingly, younger people are demonstrating a greater awareness of their hearing health and purchasing hearing aids through retail channels. There’s also the uptick in hearing aids being fitted through TPAs. But as the numbers continue to shift, we recommend that our members remain flexible to adjust to these industry changes as they occur.
Private Practices’ Pain Point
While Medicare Advantage can provide some patients with access to hearing aids, it deprioritizes the quality of extended clinical services and limits the audiologist’s flexibility for services and products. In addition, the patient doesn’t gain the substantial benefits of the continuum of care model in a traditional direct-pay treatment plan.
Lower contracted reimbursement rates don’t have to be the end of quality service. You can continue to offer a high level of service, fight decreasing revenue due to hearing aid benefit plan (HABP) contracts, find solid financial footing and thrive in today’s shifting business landscape, all while creating good health outcomes for your patients.
There are a couple of steps that you can take to understand how TPAs and HABP contracts impact your business, such as reviewing your contracts, understanding exactly what they require you to do and assessing your scheduling protocols.
Review Your Contracts
As the new year has rolled in, it’s time to review your HABP contracts. Some contracts are beneficial, but many aren’t favorable to the patient and the practice. Start with understanding which services are and, more importantly, which services aren’t covered under your HABP contracts. Medicare Advantage insurance companies contract with the HABPs to administer hearing health benefits; however, the details of those benefits are defined in the contract negotiations and can vary by plan.
That’s why you must read your provider contract and the defined plan benefit. This will help you determine what’s best for the patient, the provider and the practice.
Many HABP contracts cover testing, fitting, follow-up (up to three visits) and one year of service. While the fit and follow-up sections spell out what services are included (e.g., verification, initial programming, product training, etc.), what’s included in one year of service is not defined.
HABP contracts typically don’t cover things like device reprogramming, receiver replacement, Redux drying, cleaning ears, HIT box testing, cognitive screening, tinnitus management, aural rehabilitation and auditory training.
Understand what the contract requires you to do for their payment. If the practice provides services outside of the contract and doesn’t charge the patient directly for non-covered services, then the revenue loss is in the hands of the practice, not the contract.
Since every HABP contract is different, you’ll need to make a business decision and decide if you want to participate based on each contract’s reimbursement AND what you’re required to do for the patient to get that reimbursement. Estimate how long it’ll take to fulfill their reimbursement requirements.
Reviewing contracts can feel overwhelming, especially if you’re not familiar with the terminology or don’t know where to find the fine details that matter to your practice. Your regional team can walk you through how to read contracts. Just reach out to them.
A 3-Month Assessment
After understanding your contracts, you should conduct a three-month assessment to determine if you need to make a change. The first step is to review your scheduling protocol and allocate adequate coverage for your entire patient population, which reduces the risk that you’ll lose money by having too many low- or no-revenue appointments. Your Fuel Medical regional team can describe the process of setting up block scheduling and then help you analyze the results to determine if this approach is beneficial for your practice.
As the way patients get access to hearing aids evolves, so does our approach to scheduling, services and who does what for the patients. To move forward, you should consider reviewing your current contracts and assessing your scheduling protocol to determine if this approach to TPAs is in your practice’s best interest. Contact your regional team for more information today or read the next Ask Fuel First article describing scenarios when you should opt in and when you should opt out.