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Managed care health insurance benefits are not a new concept.

A managed care company is a third-party company that the insurance company uses to help patients with specific benefits in an attempt to keep their (the insurance company’s) costs as low as possible. Managed care in the hearing aid market has become a huge factor in ten short years.

When I started my business a decade ago, almost no one had hearing aid benefits in their major medical policies, and no one had any benefits through Medicare supplement coverage. Today, 65% of all health insurance policyholders have some hearing aid benefits, and 45% of Medicare plans also offer hearing aid benefits.

As insurance companies have been hit by the growing demand for hearing aid coverage, primarily from baby boomers reaching the hearing-impaired age group, managed care for those benefits has become the industry standard. industry. This means that if your insurance company uses managed care, you cannot go out of network and use a provider that is not in that network.

It also means that the managed care group will guide you to your dispenser, set product options, and most importantly, hearing aid prices. The hearing professional then becomes a “fee for service” participant in the process.

The managed care model quickly gained favor with insurance companies due to the reality of very high prices.

An audiologist described it this way, “It should also be noted that as someone who used to work for one of these entities, the sheer existence of these programs is partly our fault. We vehemently refuse to detail or offer any form of price transparency. We were unable to offer affordable or value-based solutions to consumers. We provide free evaluations and do not routinely adhere to evidence-based care. And finally, there were some of us who ignored our managed care agreements and played a dangerous insurance game in which all hearing aid patients were pressured to pay for an upgrade; where we billed for hearing aids that we had not fitted and would not fit until payment was received; where we made the patient pay in full, up front, even though he had a benefit; or where we charge the payer differently than we charge our general patient population. Insurers, employers, workers’ compensation plans, and most importantly, consumers, have grown tired of the game and tired of losing. Ultimately, they pushed for a defined lower cost delivery system. Now the biggest losers in the current game are the hearing health care providers.”

Not all hearing care professionals would agree with the author’s assessment and complaint. Those who would agree would be high-end priced providers who generally can’t afford to be part of a managed care network because the managed care network’s fee for service is much lower than what you would get with the profit margin from selling the hearing aids themselves. .

For example, I just heard from a new patient about a well-known regional health system with audiologists that will no longer accept his $1,500 hearing aid benefit from an even more well-known health insurance company in Pennsylvania. This is because that insurance company is now in a managed care administration and that practice has decided not to enroll in the managed care network.

There is another well-known, large health insurance company in our region that is not yet in managed care and honors out-of-network relationships with hearing aid dispensers. I’ll let you guess the names of those companies. The practice that will no longer accept patient coverage is sympathetic to women’s coverage, but cannot function with fee-for-service in contrast to the previous profit margin his company has grown accustomed to.

They can’t even access the benefits billing process without going through managed care. Sometimes the overhead of practices like this can’t absorb price reductions and stay in business as big as they currently operate. Hearing aid distributors who would disagree with the complaint in the previous article are often one-man or family practices that established a lower price model of hearing aid sales.

Typically, the managed care fee for the service is only slightly below the profit margin on hearing aid sales and is a welcome business coming through their doors. Sometimes the lowest priced provider has a dilemma with the managed care group that is priced higher than what they normally sell. The dilemma occurs when a patient refers another patient who might be charged a different and slightly higher price, something that would be quickly known in a smaller community.

The four largest managed care groups that administer hearing aid benefits are now involved with forty of the nation’s largest health insurance companies, numbering more than one hundred million policyholders. If your plan is managed care and you call your insurance company about hearing aid benefits, the operator will transfer your call to managed care and you won’t even know you’re not talking to the company you called. Managed care is great for the insurance company, the third-party managed care company itself, and generally for the consumer. The higher priced dispensers do not see it with good eyes.

With lower-priced dispensers, sometimes their retail prices are lower than the copay a patient would spend through their managed care network. It always pays to get as much information as possible before making a decision about purchasing hearing aids through managed care. Talk to your health insurance agent as most Medicare Advantage Supplement plans have hearing aid benefits.

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Jeffrey L. Bayliff is the owner of Hear the Birds Hearing Aid Center, Lock Haven.

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