Editor’s Note: The below editorial was written by American Speech-Language-Hearing Association (ASHA) board member, Dr Janice Trent.

By Dr Janice Trent

Recently, the Centers for Medicare & Medicaid Services (CMS) unexpectedly opened a new front in expanding access to hearing care by proposing to cover Medicare beneficiaries’ visits to audiologists without first requiring a doctor’s referral. Medicare’s so-called “direct access” for audiology services could be a game changer for beneficiaries with hearing loss. It would allow seniors to seek help for hearing loss without having to go through a primary care gatekeeper. By proposing this, CMS acknowledged that people are capable of recognizing a loss of hearing and, consequently, it makes little sense to put hurdles in their way toward seeing an audiologist.

Unfortunately, however, while the agency’s proposed rule may aim at facilitating easier access to audiologists for seniors, aspects of it could unleash some unintended consequences that may actually do the exact opposite by underpaying audiologists for skilled hearing evaluations and overpaying for other low-intensity diagnostic services. 

Specifically, CMS’s proposed rule would reimburse providers one set amount for any direct service — a significant departure from current policy, which leverages 36 distinct CPT codes for appropriate payments. While that would theoretically streamline things, in practice, it would be a disaster. For audiologists providing a low-intensity service, the new reimbursement amount would be higher than normal, increasing both patient cost-sharing obligations and Medicare program costs. Faced with paying higher out-of-pocket expenses, seniors on fixed incomes could choose to delay or forgo necessary care. On the other hand, for procedures like cochlear implant reprogramming, the single reimbursement amount will be painfully inadequate — so much so that many providers will be unable to justify providing the service. Neither of these outcomes is good for beneficiaries.

Additionally, the CMS proposal limits beneficiaries to one direct access audiology appointment every 12 months. While CMS may have intended to reduce overuse, this limitation would serve as an unnecessary barrier to follow-up appointments. Although those appointments are the standard of treatment, Medicare beneficiaries wouldn’t be able to return to their audiologist without first getting an order from their primary care providers. 

The potential negative impact of the “one visit per year” provision in the CMS proposed rule would be considerable. Take for example a person who receives a cochlear implant. Once the implant is placed, the patient often needs multiple reprogramming sessions. Existing standards of care call for an audiologist to periodically check for needed reprogramming. Ensuring an order is in place for each session — particularly given the physician involvement in surgically implanting the device — would be an unnecessary administrative burden for the physician, audiologist, and the patient. Similarly, a person with cancer may require ototoxic monitoring for hearing loss. The extent of this monitoring can vary depending on patient needs, but typically requires well beyond one direct access appointment for audiology services. 

I applaud CMS for recognizing the importance of providing beneficiaries with direct access to their audiologist. However, the proposed rule must align with the actual needs of persons with hearing problems and do more to facilitate provision of services. Without those changes, too many Medicare beneficiaries could end up farther, not closer, to the care they need.   

Janice R. Trent, AuD, has practiced audiology for over 30 years in a variety of clinical settings. Her diverse career has included a total of 16 years of teaching and clinical supervision at Howard University, Washington, DC, and Temple University, Philadelphia, Penn. Dr Trent has also worked as a clinical audiologist in hospital settings and private practices.

Image: ASHA