News and Updates from Private Payers

Update: United HealthGroup Hearing Aid Sales Direct-to-Consumers 

Since releasing its announcement in early October 2011 of its plan to commence a “direct-to-consumer” hearing aid program including an online hearing test, the Academy has been in communication with United Healthcare (UHC) and hi HealthInnovations (HHI), subsidiaries of United HealthGroup (UHG), regarding specific Academy concerns primarily focusing on the lack of quality of care reflected by the program. (See below for a timeline of AAO-HNS advocacy efforts.) Subsequently, on November 2, 2011, the Academy submitted comments and concerns about the program to the National Medical Director at UHC and received an immediate response resulting in an initial conference call on November 28th with UHC.  After a brief conference call, both parties thought it best to arrange a face to face meeting for a more thorough discussion.  UHC initiated its program on January 1, 2012, with the following states included in the program’s roll-out: California, Colorado, Florida, Illinois, Kentucky, Missouri, Nevada, New Jersey, New York, North Carolina, Ohio, Oregon, South Carolina, Texas, Tennessee, Virginia, and Wisconsin.

On January 30, 2012 Academy representatives including leadership, physician and audiology volunteers and staff, met with leadership members from UHC at the Academy in Alexandria, Virginia to discuss the new Hi Health Innovations (HHI) program.  During the meeting, UHC representatives responded to all of the Academy’s concerns set out in our November 2nd comment letter and provided a detailed explanation of their methodology. After gaining a more comprehensive level of insight on the program, the Academy maintains that there continue to be major flaws in HHI’s “direct-to-consumer” approach to dispensing hearing aids.   The Academy continues to have concerns regarding the inadequacy of the online testing protocol, red flag symptoms that could go unnoticed, referrals to appropriate hearing health care professionals, and noncompliance with state and federal regulations. Further, AAO-HNS does not support a “some better than none” approach to hearing health care.  As the Academy has maintained, the best practice for treatment of hearing loss involves the otolaryngologist, audiologist and patient as care team members.

AAO-HNS Health Policy senior staff have continued to be in communication with American Academy of Audiology (AAA), American Speech-Language-Hearing Association (ASHA), Academy of Doctors of Audiology (ADA) and the International Hearing Society (IHS) to share with one another any new information received from UHC.  In addition, AAO-HNS continues to maintain collegial communications with UHC to provide input on aspects of UHC’s program as it becomes further developed, keeping patient safety and quality of care at the forefront.  Further, the Academy will continue to seek additional information about how their program is in compliance with state law and FDA regulations.

If you are located in one of the roll-out states and you receive feedback from patients who have taken the online hearing test or ordered the hearing aid from this program that affected the patient’s quality of care, please contact the Health Policy Team at the Academy at healthpolicy@entnet.org.

Advocacy Effort Timeline
October 03, 2011 – Academy is alerted of Hi Health Innovations’ new hearing aid program.
October 24, 2011 – Academy comments about the program in American Medical News here.
November 2, 2011 – Comment letter sent to UHC followed by an immediate response from UHC to arrange a conference call.
November 28, 2011 – Several members from the Academy’s physician payment policy group (3P), Board of Governors Chair, and staff hold a brief conference call with UHC.  All parties agree a face to face meeting is necessary.
December 5, 2011 – The Academy follows up with UHC, sending a summary of the conference call and suggesting potential dates for a meeting.
January 30, 2012 – Academy leadership, physician and audiologist volunteers, and staff meet with UHC.

Update: Academy Stance on 50% Reimbursement for Evaluation and Management When Performed with a Concurrent Procedure

After receiving member inquiries regarding a 50% private payer reimbursement rate for E/M services when performed the same day of a concurrent procedure, the Academy maintains its stance that providers should be reimbursed in full for E/M services performed concurrently with same day procedures (or an E/M service billed with a 25 modifier).  For more on the Academy's stance on this issue, click here.

If you or your colleagues have received  50% reimbursement for an E/M service billed with a concurrent procedure on the same day, please contact the health policy team at the Academy at healthpolicy@entnet.org.

Update: Academy Representatives Communicate with Blue Cross Blue Shield Association (BCBSA) Regarding Balloon Sinus Ostial Dilation Reference Medical Policy

Since the beginning of 2011 members of the Physician Payment Policy (3P) work group and Academy staff have been in communication with staff from the Blue Cross Blue and Shield Association regarding their balloon sinus ostial dilation reference medical policy. The Academy’s Rhinology and Paranasal Sinus CMTE provided valuable input during the process.  These communications included a letter from Academy Executive Vice President and CEO Dr. David Nielsen responding to the draft reference medical policy and a conference call with members from 3P and Academy staff on the final reference policy. In all of these communications, the Academy expressed disagreement with the classification of balloon sinus ostial dilation as “Investigational/ Not Medically Necessary” and provided evidence supporting the safety and effectiveness of the procedure. Despite these efforts, BCBSA decided to keep the “Investigational/ Not Medically Necessary” designation until future studies could meet the research criteria necessary for the policy to be changed.  One study submitted by the Academy (Plaza, et al) was acknowledged to be the type of literature needed to revise coverage determinations but was, unfortunately, deemed insufficiently powered to change this BCBSA policy.

Note that the BCBSA Reference Policies are available for use by each BCBS Plan in making independent decisions about medical policy. Each Plan may adopt the reference policy in whole or in part, may modify it, or may reject it. These reference policies are developed by BCBSA staff and then reviewed by a BCBSA Medical Policy Panel (MPP) comprised of senior Plan medical directors.

The Academy has been, and remains, ready to cooperate with appropriate industry and other groups to develop requested prospective studies that could evaluate the efficacy and safety of devices and raise the level of evidence. The BCBSA Medical Director stated that there was no reference policy on denying payment for an entire surgical session when one portion or element was considered “Investigational/ Not Medically Necessary”. The Academy will continue to work with BCBS plans, and any others with similar policies, to allow the balloon to be used as a tool to complement a procedure without the entire procedure being denied. The 3P work group strongly believes that the use of a balloon as a tool in a standard approach to a sinus ostial dilation is acceptable. If you receive this type of denial, please forward information including an EOB/Explanation of Benefits (HIPAA information redacted), indicating whether or not the full session is being denied and in what setting the procedure is being denied to healthpolicy@entnet.org so we can continue to track these. Please also let us know if your local BCBSA Plan is covering and paying for balloon sinuplasty.

Cahaba GBA Changes “Once in a Lifetime” Policy Following Academy Advocacy- (10-12-11)
After learning about the inclusion of several procedures on the "Once in a Lifetime" procedure list, the Academy worked with Cahaba CBA to have procedures the Academy believed could be performed again during a person's lifetime removed from the list. The Academy sent a letter to Cahaba explaining why these should be taken off the list, and as a direct result of the Academy's efforts, they were removed. If you have trouble with any of these procedures being deemed "Once in a Lifetime", please contact the Health Policy team at healthpolicy@entnet.org to notify us.

Major Win Regarding United Healthcare (UHC) Policy on Rhinoplasty – (04/07/2011)
Although UHC had previously informed us on March 2 that it would not revise its policy, Rhinoplasty, Septoplasty and Repair of Vestibular Stenosis, further, on March 29, we received notification from the insurer that it had revised the policy. Changes include the removal of all references to “anterior (primarily cartilaginous)” from the requirements for coverage and indicating that isolated septal spurs generally do not cause a physiological impairment etc. The revised policy will be effective on May 1, 2011. We sincerely thank all the specialty groups and the Otolaryngology Administrators (AOA) involved in this effort. View UHC’s response. If you receive non-certifications, please contact your local UHC medical director and copy healthpolicy@entnet.org on the request and outcome.

Advocacy Effort Timeline
August 2010 - Academy is alerted about the initial policy
September 2010 – Academy collaborates with the AAFPRS, ARS, ASPS, and ASAPS and sends a letter to UHC
December 2010 – UHC responds to the September letter and agrees to a conference call (on 1/18/2011) with physician leaders and staff from the Academy, ARS, ASPS, and the AAFPRS
January 2011 - After conference call, UHC further revises the policy but there are still outstanding issues
February 2011 – The Academy and the other involved specialty groups send a follow-up to UHC addressing these outstanding issues
March 2, 2011 – UHC responds that it will not make any further changes to the policy until February 2012 as the insurer’s policy review cycle for 2011 has ended. UHC will only consider revising the policy before February 2012 if it determines that UHC medical directors are consistently misinterpreting the policy and/or if it is causing undue burden to patients and physicians.
March 29, 2011 – UHC sends a letter to us detailing changes it has made based on the feedback we provided in our February 17 letter.

Page Last Updated: February 1, 2012