Medicare Direct Access to Audiologists – Defined!. Linda Jacobs-Condit Wayne Foster Tom Hallahan. What is Direct Access? . Client Physician Audiologist. Direct Access to Audiologist.
Direct Access to Audiologist
The ability to see a patient without a referral from a physician or other health care provider.
Limits beneficiary choice of providers
Increases costs to Medicare program
Increases wait time to see an Audiologist
Inefficient use of physician resources
Administrative burden on audiologists to track down referral if patient comes in without one
Audiology services are recognized for Medicare purposes as a diagnostic test under the Social Security Act (Sec. 1861 (s)(3))
Regulations require that diagnostic tests be ordered by a treating physician for the purpose of using the results of the test in the management of the beneficiaries’ specific medical problem. (42 CFR 410.32)
Major Point: Supplier Status is not the same as Direct Access
Beneficiaries could go directly to an audiologist.
Audiology will remain a diagnostic benefit.
Medicare will not pay for services deemed not medically necessary or perceived as a screen.
Need to develop additional education of patients on Medicare coverage policies and exclusion of audiology services related to hearing aids.
How to ensure FDA Red Flag regulations are followed by the audiologist
Medicare Improvements for Patients and Providers Act (MIPPA) defined audiologists as eligible to participate in PQRI.
Until recently no audiology quality measures existed that could be used by the profession.
Possible Solution to Physicians’ ConcernsPhysician Quality Reporting Initiative (PQRI)
AQC developed 12 measures – many based on FDA referral requirements.
CMS, in the Medicare Physician Fee Schedule final rule announced three audiology referral measures for PQRI.
Possible Solution to Physicians’ Concerns
Physician Quality Reporting Initiative (PQRI)
2010 PQRI Quality Measures for bonus payment:
Let’s look at each of these challenges.
* CMS – Centers for Medicaid and Medicare Services
Physician referral policy:
Direct Access Conclusions
Comprehensive Audiology Benefit
Historically Congressional Budget Office (CBO) factors in woodworking effect*.
No concrete data on cost of direct access or comprehensive benefit
High cost requires an off-set in the Medicare programComprehensive Audiology BenefitCost/Fiscal Impact on the Medicare Trust Fund
* Woodworking Effect: If benefit is available –more providers will enroll and beneficiaries will access.
Direct Access is only one facet in Medicare recognition of audiology services.
Need recognition of full scope of services – rehabilitative and habilitative treatment
Medicare audiologic benefit would improve services to clients
Collaboration with AAA, AAO-HNS
Need for more information on cost of direct access/ expansion of services
Buy-in from Medicare
Continue to convene the audiology consortium addressing PQRI
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Letter from Robert H. Roswell MD, Under-Secretary for Health, U.S. Dept of Veterans Affairs to Senator Ben Nighthorse Campbell, April 15, 2003.
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Director, Federal & Political Advocacy, ASHA
Director, Government Relations & Public Policy, ASHA
2009 GRPP Board