Understanding Where the EOBs (Evidence of Benefits) Charges Come From
If your like most Americans health insurance is hard to understand. It is hard to understand how the Government system of Medicare works, how insurance pays, doesn’t pay, and how much it pays. Most people have trouble understanding EOBs (Evidence Of Benefits). We have trouble understanding why some CPTs (Clinical Procedure Codes) are paid and others are not. We can’t understand why the doctor or hospital charges so much and our insurance pays so little. We are also having difficulty even finding a doctor that takes our insurance, especially Medicare. This little story may shed some light on EOBs, private insurance and the Medicare process from the provider side.
First, Medicare is not the same for everyone in the USA. You would think a government plan would have the same rules and coverage for every citizen. Let me tell you, that is just wishful thinking.
The United States Medicare system is divided up into areas called MAC Jurisdictions. MAC stands for Medicare Administrative Contractor. These MACs are independent contracted companies who run an area of the USA. Each MAC is allowed to make their own rules on how to interpret Medicare payment. So to minimize expenses, they make rules on what tests and procedures are allowed, when they are allowed and how many are allowed per year. These rules are called Local Coverage Determinations or LCDs for short.
So what you thought was a government run program really isn’t. If you live in one state you may be covered for a service and then move to another state and you may no longer be covered for the same service even if CMS (the Centers for Medicare and Medicaid) says you should have coverage for this service.
The next strange thing about Medicare is something called a RAC (Medicare Recovery Audit Contractor). RACs became permanent with The Tax Relief and Health Care Act of 2006. The RAC is supposed to identify improper Medicare payments – both overpayments and underpayments. Here is the bad part; RACs are paid based on the errors they find on providers’ claims. In theory, it sounds good to have the company looking for errors paid by the amount of errors they find. In theory this would encourage the RAC to find errors in provider’s claims to keep costs down. Unfortunately, then RACs were given the ability to make up their own interpretations of Medicare rules. So you just put the fox in charge of the hen house! How would you like it if you had a set of complex rules you are following. Then you are audited with a new set of rules you can’t know, just so you can be heavily fined and put out of business! This is what is happening to clinical providers and clinics across the nation every day.
Then comes the confusing part of each procedure code, the payment. The system is not very accurate regarding the amount of time, equipment cost, and interpretation is involved for a procedure. CMS tries to properly adjust this, but it is based on the input of providers who may or may not be indicative of all who bill the code. First, it is a zero sum system. This means if one group lobbies to have reimbursement increased for their code or to have a code added for a new procedure, other codes must be reduced by an equal amount so that there is no change in the overall amount reimbursed for all codes. CPT code 92557, Comprehensive Hearing Test requires a minimum of 15 minutes of time if the patient is alert and cooperative to test. The test requires equipment that costs $30,000-60,000. The global CPT code is supposed to include interpretation and report time. The problem is this is based largely on providers which do not write a full report, just a line or two on the test itself and then hand the report to physician in the same office/clinic who writes a final report. The physician can bill an Evaluation and Management code for this time and the history taking time. So for a private practice audiologist who takes a case history, counsels the patient and spends time writing a report to the referring physician the time it takes is closer to an hour rather than 15 minutes. The audiologist also cannot bill Medicare for Evaluation and Management. For this hour, Medicare pays $37.47. To put this payment in perspective, a plumber charges about $250 just to walk into your house and talk to you about your plumbing issue. An audiologist, with a doctoral degree (8 years of college) would have to do over 6 tests in one hour to be paid as well. Now you can begin to understand why a provider pushes you through their office in 10 minutes. It is not what you or they want, it is what has to be done to meet the overhead of a business with payment this low.
There is a lot more wrong with the system. You have likely seen items on your EOB where your physician or hospital charged three times more than they actually received for the procedure. Why do we charge so much when we will only receive one third or one fourth of the amount we billed? Why do we bill more than “reasonable and customary”?
This is the craziest thing in medicine. In order to be paid we have contracts with insurance companies. These contracts are top secret. No provider can know what another provider is reimbursed. So Dr. Y does a test and gets $15 and Dr. X does the same test and gets $22 only because they negotiated a better contract, not because they are a better doctor. In order to keep the whole system “hush hush”, doctors must bill 2-4 times what is the Medicare reimbursed amount (the only amount everyone knows) so that all their contracts will pay the maximum they are allowed on the contract they negotiated. Then we have to write off the remainder we over billed just to get the amount our contract has agreed to.
If you are thinking that is stupid, you are right. How stupid is a system where you have to bill huge numbers to get the real number you negotiated up front(and already know), but can’t let anyone else know? Then to make it even crazier, the contracts are written to say things like 110% of 2008 Medicare RVUs (Relative Value Units). Which means you will be paid 110% of what the Medicare Rate was for that CPT code in 2008. Other contracts are written to say 40% of billed charges. So on a 40% contract, to get paid the $30 I negotiated in payment contracts from Insurance Company Y, I must bill $75 and write off $45. So the patient sees that I bill $75 for something the insurance company says is only $30 for ‘reasonable and customary’. I look like a creep for over billing the patient $45, when in reality I am just playing the game the way the insurance company makes me play.
If you got to the end of this blog confused by the insane system of medical insurance, you are in good company.
The High Cost of Hearing Aids Revealed
I frequently hear people saying things like “wow, hearing aids cost a lot” or “hearing aids are too expensive”.
So to take a better look at the high cost of hearing aids, I wanted to take a moment to point out some simple math:
Every month the average American spends on basic services: $55 on cable service, $50 for cell phone service (not a smart phone); $35 for Internet (if you live in a metro area)
- For LOW END Cable/cell/Internet service
= $140/month for cable, cell, Internet
= $8,400 for 5 years
- For higher coverage: Better cable $90/month; Smart phone service $120/month,
High speed Internet $60/month
=$270/month for higher level cable, cell, Internet
= $16,200 for 5 years
Hearing aids in comparison
- The average PAIR of the BEST high end hearing aids will last 5 years or you can consider upgrading in 3 years to new technology.
=$7000 for 5 years
- To upgrade every three years to a pair of the BEST hearing aids here are the costs:
=$7000 for 3 years
The high cost of hearing aids?
So to have the best pair of hearing aids available ($7000) , it costs less than the worst cable, cell service and Internet service for the same amount of time ($8400).
Having the best pair of hearing aids available ($7000) every three years even costs less than the better cable, smart-phone and high speed Internet services for 3 years ($9720).
Hearing aids help prevent:
- decreased earnings
- Alzheimer’s Disease
- social isolation
So I say to you now, why are the costs of simple service items like cellphone, cable, and Internet so expensive?
The High Cost of Hearing Aids – WHAT A BARGAIN!Terri Ives, ScD, AuD Board Certified Doctor of Audiology Hearing and Balance Institute of the Rockies, Inc.
Dizziness Herbal Cures and Remedies: is it safe to try one?
Dizziness herbal cures are all over the Internet, TV, magazines and your local pharmacy. You have been suffering from dizziness and want it to go away now. The labels sound wonderful. The dizziness herbal cures promise relief from dizziness, nausea, vertigo if you buy them. You think, “it couldn’t hurt to try it, after all it is “all natural”, “safe”, “FDA Registered” and has a “money back guarantee”….so why not?” Let me give you food for thought.
That innocent looking bottle of hope could countain ingredients that are actually poison. Yes, your local innocent drugstore may be selling dizziness herbal cures you should think twice (or more) about before buying. I am not anti-homeopathic medicine or trying to scare you. I just believe in informed decisions. You need to consider the side-effects of anything you put into your body. How does this drug (it is a drug too) interacts with the medications or herbals you already take? Just because it is natural may not mean it is safe.
Examples of some dizziness herbal cures on the market:
Here is an example of two dizziness herbal cures which contain ingredients known to be toxic/poisonous: VertiFree and ZyVestra. Both of these over-the-counter dizziness herbal cures claim they are safe and at therapeutic dosage, but as I point out below, this is not regulated. Even though the ingredients may be listed in the “Homeopathic Pharmacopoeia of the United States” you must trust the company to verify and assure they are at safe levels.
Ingredient number one contained in these is Levant Berry (cocculus indicus). This herb has been been largely abandoned for use in the USA and Europe due to safety concerns. Whole fruit berries are even used in some countries to kill birds or dogs. It is considered unsafe to take by mouth and the chemical in it, picrotoxin, can cause DEATH even in small amounts. Cocculus Indicus is also considered to be unsafe when put on the skin. It may cause side effects such as: headache, dizziness (hmmmm- wasn’t that supposed to be what it was curing?), nausea, diarrhea, rapid breathing, sleepiness, irregular heartbeat, decreased heart rate, unconsciousness and death.
So let’s assume the selling companies have reputable hemopathic herbalists and have the therapeutic level correct in the medications. A peer reviewed research study published in a REAL scientific journal , Psychology and Behavior in 2007 did a comparison of cocculus indicus vs. placebo (sugar pill) in controlling nausea and vertigo after the research subject were in a flight simulator which induced spatial disorientation (motion sickness). The testing was repeated 3 days separated by at least 2 weeks with the subjects and testers not knowing which medication they received. There was no improvement in sickness or vertigo and in fact postural instability (poor balance) increased in the group taking the cocculus indicus!
Ingredient number 2, Gelsemium sumpervirens: All parts of this plant are very poisonous. Even small amounts can cause serious toxicity, including DEATH. Symptoms of poisoning include headache, vision problems, difficulty swallowing, dizziness (hmmmm there we are again with what it was supposed to cure) muscle problems, seizures, breathing problems, slowing of the heart and is very dangerous to use if you have a heart problem. It can poison children very easily. It is currently being tested in mice for regulating anxiety behavior. A research study published last year on heart rate variability in humans showed significant heart rate disruption with this plant.
I don’t have the space to go into the many other ingredients and dizziness herbal cures I have seen on the shelves and in my practice that patients have tried in hope of relief from their dizziness.
Before you believe the claims a marketing company put on the lable of one of these dizziness herbal cures, look up the ingredients on WebMD or the National Institutes of Health website http://ods.od.nih.gov/factsheets/list-all/. Look for peer reviewed scientific journal research on PubMed before you believe claims. Be an informed consumer. Like a favorite show of mine used to say… The truth is out there.
Additional Info: The “FDA Registration” does not mean it is tested or safe. Section 211.137 specifically exempts homeopathic drug products from expiration dating requirements. So what you have purchased may be so old it doesn’t work anyhow! Furthermore, homeopathic drug products are not required to give information on the strength of each active ingredient. So you have no idea if the levels of the drugs in the over-the-counter ”cure” you just purchased are below therapeutic levels or could be unsafe.
If it seems to good to be true, it probably is.
At the Hearing and Balance Institute we fit primarily 30-50 year olds with hearing aids. Most of this is due to music induced hearing loss that could have been prevented. I frequently find when performing a hearing evaluation on a young child (we are talking 8-10 years old here folks) a major noise induced hearing loss. How do I know it is from noise? Noise, no matter what generated the sound- a violin, iPod, gunshot, rock band or chainsaw, gives hearing loss in the area of 3-6kHz.
How much noise damages hearing depends on many things.
1st: How loud is the sound: the louder the sound above 80 dBSPL-A the greater your chance of hearing loss
2nd: How long did you hear the sound: the longer you listen to a sound over 80 dBSPL-A the greater your chances of having a hearing loss.
3rd: luck of the draw… why do I say that? Because some ears are just lucky, they can listen to loud sound for long periods of time and never suffer hearing loss. The vast majority of ears suffer hearing loss. Some are very unlucky and suffer tremendous hearing loss with very little exposure to loud sound.
In general the louder the sound the less time you have to safely listen to it.
The days of noise induced hearing loss being related only to loud occupations or serving in the military are gone. Now I see more people with hearing loss in need of hearing aids at a young age due to listening to their favorite tunes and going to concerts and clubs/bars.
So how can you prevent noise induced hearing loss for yourself or your kids while still enjoying the music and looking great?
Let’s face it, even though I know better as a Doctor of Audiology, I don’t use the little yellow foam plugs at a concert because they are too hard for me to get in my ears, make the music sound terrible and look weird. So here is what the wonderful road crews for great bands are now doing to protect their hearing, I have done and you can do:
For personal listening:
1. use earphones that block out outside sound. I completed research sponsored by Etymotic Research with Brian Fligor, ScD several years ago which proved the more you blocked out the outside sound, the lower (therefore safer) the level you set your iPod at.
2. for better sound quality while also blocking out the outside sound, use IEMs (In-Ear-Monitors). These are custom made ear phones like musicians wear. They deliver the best sound quality and allow you to have custom designs and colors like your favorite team or band.
3. you can also get custom molds to adapt to your earphones. These are made for your ear and block outside sound but you insert your earphone into them.
Both of the custom solutions require you to come and see us at Hearing and Balance Institute of the Rockies for impressions of your ears. We include a free hearing screening.
4. If you own an iPod, look in the menu under “settings”, “music” and you will see something called “Volume Limit” just turn that setting “on” and you are now assured your listening level is kept safe. Then if you don’t have any type of earphones but the ones that came with your player, you are still listening at safe levels.
For Concerts/ Clubs/ Bars :
The best solution is a set of musician earplugs like Etymotic Research ER-25. This will change your safe listening time from less than 15 seconds to approximately 4 hours. You can have them in clear or in fun colors, glitter or swirls of colors. They fit comfortably for hours. The best part is the music sounds correct, just more quiet so you can truly enjoy it and save your hearing for the future.
So now you have no excuse to have music induced hearing loss! Prevent hearing loss, look great and have fun!
People with Diabetes More Likely To Suffer Hearing Loss
A study published by the Annals of Internal Medicine suggests that patients with diabetes are more than twice as likely to suffer hearing loss as those without diabetes.
In the study, National Institutes of Health (NIH) researchers analyzed data from hearing tests administered in the National Health and Nutrition Examination Survey (NHANES) to 5,140 participants between 1999 and 2004.
The link between diabetes and hearing loss was evident across all frequencies, with the strongest association in the high frequency range. Those with diabetes suffered from hearing loss in the low or mid frequencies of sound at a rate of 21% compared to 9 % of the same age adults without diabetes. For high frequency sounds, 54% of people with diabetes were found to have hearing loss compared to 32% in those who did not have the disease.
Adults with pre-diabetes, whose blood glucose level is higher than normal but not high enough for a diabetes diagnosis, had a 30 percent higher rate of hearing loss compared to those with normal blood sugar.
For years, physicians who treat people with diabetes have counseled that their patients to receive regular vision check-ups. This important study underscores the need for patients to request to have their hearing checked as well. Many insurance companies now cover annual hearing evaluations, and most if not all cover hearing evaluations if you suspect you have a hearing loss.
Diabetes may lead to hearing loss by damaging the nerves and blood vessels of the inner ear. Autopsy studies of diabetes patients have shown evidence of such damage. A hearing evaluation can be invaluable in identifying diabetic patients with potential hearing loss and giving them an opportunity to receive the treatment they need.
Studies conducted by the Better Hearing Institute, a not-for-profit educational organization whose mission is to educate the public about hearing loss treatment and prevention, show that people with untreated hearing loss experience a lower quality of life than people with normal hearing or people who use hearing aids. Hearing loss of any level has been shown to decrease financial earnings. Research has indicated an increased possibility of dementia or Alzheimer’s disease in those with untreated hearing loss.
Isn’t it time you had your hearing evaluated?
The inner ear is highly vascularized and extremely sensitive to disruptions in blood flow. Studies have shown that a healthy cardiovascular system has a positive effect on hearing. Conversely, inadequate blood flow and trauma to the blood vessels of the inner ear can contribute to hearing loss.
Some researchers hypothesize that because the inner ear is so sensitive to blood flow, abnormalities in the condition of blood vessels in the cochlea could be noted earlier than in other, less sensitive parts of the body. In one study, it was hypothesized that low-frequency hearing loss may be a marker for predicting the presence or potential development of cardiovascular disease. (David R. Friedland MD, PhD, Associate Professor of Otolaryngology and Communication Sciences at the Medical College of Wisconsin- Madison presented at the 2009 Combined Otolaryngology Spring Meeting)
Moreover, in a study published in the June 2010 issue of the American Journal of Audiology by Raymond H. Hull and Stacy R. Kerschen reviewing 60 years of research, found the negative influence of impaired cardiovascular health on both the peripheral (ear) and central (brain) auditory system and the potential positive influence of improved cardiovascular health on the auditory system has been noted extensively.
According to a study in older adults, the prevalence of suffering from various degrees of hearing loss is 54% greater among those who have a history of heart disease than in the general population. The study also found if individuals exercised at least once a week, they saw a 32% reduction in the risk of suffering from hearing loss, when compared to sedentary people. (“The Association Between Cardiovascular Disease and Cochlear Function in Older Adults.” Population Health Program Faculty, Wisconsin University, First Annual Population Health Poster Session selected abstracts 2001-2002.)
More about Hearing Loss
Numerous studies have linked untreated hearing loss to a wide range of physical and emotional conditions, including impaired memory and ability to learn new tasks, increased risk of dementia and Alzheimer’s disease, reduced alertness, increased risk to personal safety, increased risk of falling, irritability, negativism, anger, fatigue, tension, stress, depression, decreased job earnings and diminished psychological and overall health. However, treatment of hearing loss, particularly when it can first be treated is able to greatly reduce or completely remove these risks. Even better, nine out of ten hearing aid users report improvements in their quality of life.
So get or stay in shape, schedule your annual hearing test and treat your hearing loss right away.
Despite years of graphic anti-smoking campaigns and public smoking bans, people continue to light up – especially at home, where more than half of American children and teenagers are exposed to secondhand smoke. Scientists believe that passive smoke either causes or exacerbates lung cancer, asthma, learning disabilities, heart disease and other conditions; and now a new study finds that teenagers exposed to tobacco smoke may also have significant hearing loss – and not even know it.
Researchers from the New York University School of Medicine tested over 1,500 adolescents aged 12 to 19 for blood levels of cotinine, a byproduct of nicotine that forms when people are exposed to tobacco smoke. Nicotine is the main substance in tobacco that causes dependence/addiction. They also tested the teens’ ability to hear high-, medium- and low-frequency sounds.
Teenagers who’ve been exposed to secondhand smoke have roughly double the risk of hearing loss compared to those with little or no exposure. The more these teens have been exposed to tobacco smoke, as measured by their blood levels of cotinine, the greater their risk of significant hearing loss. Teenagers with the highest levels of secondhand smoke exposure had nearly triple the risk of hearing loss.
They weren’t deaf, but their hearing was measurably impaired. And a startling number of these teens – over 80 percent – had no idea that they had significant hearing loss. “It’s kind of surprising,” says Dr. Joseph DiFranza, as quoted by Reuters Health. “We already knew that passive smoking is bad for children,” but “this just piles on another reason” to keep tobacco smoke away from kids.
Hearing impairment was especially noticeable in the mid- to high-frequency range, which means the adolescents might have difficulty understanding speech. The consequences of mild hearing loss, which researchers suspect may be due to damage to the ear’s delicate blood supply, are subtle yet serious. This could result in problems at school, where they may be singled out as troublemakers, fail at social interactions, or be misdiagnosed with ADHD or other behavioral problems.
The obvious first step is to minimize children’s and teen’s exposure to tobacco smoke. Hearing testing is another important step: Infants are regularly screened for hearing loss, but there are no guidelines for hearing tests past the early school years. One researcher noted that all children and teenagers exposed to secondhand smoke should be regularly screened for hearing loss, in case hearing aids are warranted.
Our patients LOVE their hearing aids. Many people are unhappy with the hearing aids they’re prescribed. At the Hearing and Balance Institute, 93.7% of our patients report being very happy with their hearing aids. Our expert Doctors of Audiology work with many different manufacturers, therefore we can offer hearing aids at a price level, technology and style that is tailored just for you.
We make hearing aids affordable. We understand the financial investment in hearing aids can be daunting for some people. That’s why we offer quality hearing aids for every budget, as well as 0% interest payment plans. Don’t let money worries prevent you from getting the treatment you need. Losing your hearing can cost you much more in the long run than the cost of hearing aids.
Our tinnitus treatments actually work! A tinnitus evaluation is more than a routine hearing test. It requires specialized equipment and advanced knowledge and expertise that only our Doctors of Audiology provide. Our doctors will take the time to understand and identify the characteristics of your tinnitus so they can customize a proper, clinically proven and effective treatment plan.