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A Battle Won: CMS Approves Cochlear Implant-related Reimbursements

Laberta, Valerie

doi: 10.1097/01.HJ.0000491110.42015.74
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While the entirety of health care is struggling to contain costs, there are those battling to get their fair share of reimbursement dollars. To be clear, it is a righteous crusade with more than the clinicians’ relative wealth hanging in the balance; fair reimbursement also clears patient barriers to quality care.

One arm of the effort involves reimbursements for cochlear implantation (CI) surgery and associated services, including device programming for individual customization of this life-changing technology.

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“Low reimbursement rates are likely contributing to the low incidence of cochlear implant surgeons and audiologists, which, in turn, limits the availability of cochlear implantation to the public,” said board-certified otolaryngologist Sreek Cherukuri, MD, founder of MDHearingAid. This is a point echoed by other experts in the field.

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IDENTIFYING BARRIERS TO CARE

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“Without appropriate payments, hospitals and clinics begin to consider CI-related audiology services as fiscal ‘losers,’” explained Donna L. Sorkin, MA, executive director of the American Cochlear Implant Alliance (ACI Alliance), and a CI recipient herself. “That translates into underinvestment in clinical care, resulting in long waits for patients seeking appointments–a significant barrier to care.”

ACI Alliance (www.acialliance.org), a not-for-profit organization established in 2011, has been instrumental in encouraging greater access to CI through its triumvirate of objectives: research, advocacy, and awareness. The organization's efforts include raising CI awareness through outreach to the general public, patients, and the medical community; developing and/or sponsoring research and clinical trials that demonstrate the benefits CI technology and its links to health and wellness; educating health care plan executives and government officials about CI technology, its economic and social benefits, and the relative value associated with coverage; and organizing collaborative efforts to foster new research and encourage best clinical practices for standardized outcomes.

In 2015, ACI Alliance went on record with the Centers for Medicare and Medicaid Services (CMS) to advocate for change in the Ambulatory Payment Classifications (APCs) across Medicare's Outpatient Prospective Payment System (OPPS) relative to CI and Auditory Osseointegrated Implants (AOS).

“We are very conscious about the need to help Medicare operate optimally,” said Sorkin. She noted that government plans including Medicare and Medicaid cover only about 34 percent of CI surgery cost and do not adequately reimburse the actual cost of services. As such, Sorkin stressed the importance for hearing health professionals to help hospitals recognize the full value of CI-related services.

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WELCOMING CHANGE IN APC

“We've known for some time that the APC to which programming was assigned was the wrong Medical Payment Coverage (MPC). We suggested in our comments to CMS that the APC in the outpatient setting was not representative of the skills of the provider professionals,” Sorkin explained. “The surgery and the follow-up programming are totally different services, performed by a different set of individuals. The APC for programming really did not represent the higher diagnostic testing for programming that is distinct from the surgery. We made the point that this is performed by highly trained audiologists who specialize in cochlear implant programming. In short, we wanted programming to be in an APC that better represented the specialized knowledge and skills of these audiologists.”

The request was granted when, on Jan. 1, 2016, CMS elevated programming services from APC 0365 that paid $117.95 in 2015 (before geographic adjustment) to the higher level APC 5721 that pays $129.75 in 2016 (before geographic adjustment).

“We're looking at about an additional $12 in payment as compared to the prior APC. It certainly is not a huge increase,” admitted Sorkin, “but it better represents skill levels. And any improvement is progress.”

Reimbursement for implant surgery performed in a hospital setting was also increased slightly. CI reimbursement rose by 2.4 percent to $30,421, and AOS reimbursement rose by 3.1 percent to $10,538.

“I am grateful that Medicare has increased reimbursement,” said Cherukuri, “but I'm also hopeful that more positive changes will be coming.”

The actual cost of CI programming varies widely by region and practice, but one California clinician's rough estimate for actual cost is $500—a far cry from even the updated reimbursement rate.

In addition, CI follow-up services are particularly time-intensive, stretching the reimbursement over longer patient visits. “Audiology services following CI are among the most time-consuming, and yet they remain among the most under-reimbursed,” said Ginger Stickney, PhD, FAAA, senior audiologist and director of Cochlear Implant Services at the UC Irvine Medical Center. These services include but are not limited to electrode-by-electrode mapping, customized programming to avoid side effects while maximizing speech intelligibility and listening comfort, and notably, counseling. “The amount of time we need to spend with the patient is extensive,” Dr Stickney explained. “It is very rare to complete a patient visit within an hour. A lot of this time involves equipment issues; when equipment is the focus of the visit, the time is not reimbursable.”

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CELEBRATING YET ANOTHER VICTORY

The CMS included another positive change in its ruling. It reversed an earlier decision that disallowed separate payments for disparate services delivered at a facility on the same day.

ACI Alliance presented insurance claims data to support the fact that a great many instances of same-day hospital services are unrelated. “Before this new ruling, if a patient went to an outpatient setting and had programming done for their CI, then had something else done that day unrelated to their CI—for example, a visit to physical therapy for a back issue, hypothetically. Medicare would only pay for one service provided. This was patently unfair,” said Sorkin.

The CMS database was examined and the findings confirmed the contention that the services typically were not related. “Patients try to be efficient with time and effort, and often consolidate their various needs into a single day when going to a health care facility. We said to CMS, ‘Look at the data. Different services in unrelated disciplines should be paid, even if received on the same day.’ CMS agreed and changed the rule.”

The provision of payment for same-day, unrelated, out-patient services at a single facility is yet another battle won in the reimbursement wars. “That was really a victory,” said Sorkin.

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PROMOTING PROFESSIONAL VIGILANCE

These small victories bring patients closer to better hearing health care. But more work needs to be done. ACI Alliance has now undertaken a CMS-sponsored study to examine Medicare CI candidacy criteria, which is more stringent for its insured individuals than the FDA guidance for individuals under 65 years of age.

“We hope the study will lead to a change in this candidacy criteria. FDA's criteria indicate that an adult can have up to 50 percent hearing in the ear to be implanted and 60 percent bilaterally. CMS criteria for Medicare-covered patients is currently 40 percent,” explained Sorkin. “This is important because two factors affect adult outcomes. One is duration of deafness and the second is the amount of residual hearing a person has. The more residual hearing for someone who is a candidate, the better that individual will perform with a CI. Carrying that forward, we want people to have access to implantation when they will benefit the most.”

Furthermore, the Alliance believes that audiologists must be better educated about the need to refer for CI when appropriate. “Adult access to CI is unsatisfactory,” said Sorkin. “Audiologists don't necessarily refer when a patient is no longer getting adequate benefit from a hearing aid. But they should know that when a patient's hearing loss has moved into the severe or profound range they should be evaluated according to CI criteria.”

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Weston Harris, CEO of Harris Hearing Center and FDA-registered manufacturer of hearing aids for more than 15 years, has only praise for this green light to widen CI access. “We are thrilled to see the continued support from Medicare in helping the profoundly hard of hearing to achieve the best technology to assist with their condition,” Harris told The Hearing Journal. “Whether a patient needs a cochlear implant or an Auditory Osseointegrated Implant, these technologies are life-changing. Too often patients simply can't afford to avail themselves of the technology without this crucial assistance. I urge the best efforts of all interested parties to continue their support, and to keep improving our collective ability to help those in need. I hope the continued requests to CMS to improve billing will be considered for best consistency and ability to help those we are here to serve.”

Sorkin agreed with Harris. “The overarching message is that this is extraordinary technology that is underutilized in our country. We all have the capacity to improve access by helping patients know what is available and how it can benefit them. Everyone within the hearing health care system has a responsibility to help patients understand and reach access.”

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