Interview with Cindy Beyer, Au.D., HearUSA
Topic: Should I Join a Network? The Value of a Network for Providers, Patients and Benefit Sponsors
CAROLYN SMAKA: Good morning, Cindy. Thanks for your time today. Can you tell me about your background and your role at HearUSA?
CINDY BEYER, Au.D.: Sure. My title is Senior Vice President of Professional Services. I've been with HearUSA since 1987 and have been fortunate to work in many different capacities with the company, from center operations to quality management as well as contracting and compliance. My primary responsibilities now are third-party strategic relationships, as well as accreditation and network operations. Prior to joining HearUSA, I was director of a hospital-based audiology clinic in West Virginia. I have an Au.D. from Salus University.
SMAKA: You mentioned being responsible for network operations. Can we get in to some definitions - what defines a 'network' and how is that different from a 'buying group'?
BEYER: An organized network has a well defined process in place where it receives applications for participation with a peer review process, as well as standards for joining and performance. Ideally, a network has a credentialing process in place to ensure applicants are well qualified;it wouldn't be open for just anyone to join. An organized provider network has established standards of care and participation, with a very legitimate business structure. Participants agree to abide by the rules and there is a formal relationship in writing between the network itself and what are referred to as the downstream providers. Those providers, in fact, give the network the legal ability to contract on their behalf. There are many contractual obligations within the agreement, which spell out the requirements for each party and each of the responsibilities are clearly defined. The primary focus of a network is to provide a distribution system for the delivery of care as opposed to generating the sale of units. So in addition to having the provider structure, networks also have contractual agreements with third parties that intend to use the network for delivery of care.
A buying group's principle function is typically to generate the sale of units through their organization, and they usually tie discounts to that. They may have some associations with third parties that may help to generate those units as well.
That's not to say that the two of these cannot complement each other, but a buying group is not necessarily a network, and a network may have a buying group function, or not.
SMAKA: Is this terminology consistent across organizations? How does the audiologist determine, "Is this a network, or is this a buying group?"
BEYER: I think there's great variation in the way that the networks and buying groups conduct their business and in the way that each of us communicates with our providers. Some franchises are networks, so there is some kind of paperwork involved, and the expectations are spelled out in the franchise agreement. That type of agreement will look very different from a HearUSA credentialing application and network provider agreement. Because HearUSA is accredited and because we have strong ties with the Medicare Advantage and Medicaid programs, our language is going to be very clearly defined and likely more descriptive than what we might see in less binding relationships. Buying group agreements are generally more or less along the lines of, "I'm a licensed provider and I agree to purchase X number of units from you, and in turn I'm going to get this specific discounted pricing". There may be additional advantages or programs that are spelled out between the buying group and the provider.
When a network is contracted with health plans, there are very specific obligations on their part- everything from medical record storage, to how their members are charged, to filing for reimbursement, to the obligations of the provider after the sale of the hearing aids, and even including malpractice, liability, office hours, and standards of care. These requirements are spelled out in a very detailed network agreement and the focus is on patient care, rather than in a buying group agreement that may simply state, "I agree to buy so many hearing aids from your organization."
SMAKA: So the health plan can stipulate and know exactly what their members can expect when they go to this network because it's all laid out in the agreement?
BEYER: Yes. For example, in the case of HearUSA, we have a single comprehensive agreement with our providers, and it is inclusive of the third party language, the obligations of the provider, as well as the obligations of HearUSA. It's a lengthy document because the health plans require those types of protections from an organization that will have direct access to their membership. The agreement also includes all of the regulatory matters that concern our providers, like HIPAA and security. From the provider agreement, HearUSA can then contract on behalf of our provider network with health plans, benefit sponsors and employer groups. We have over 500 contracts at HearUSA, and we publish them into a manual for the providers. From the provider's perspective, it can be very confusing because there are hundreds of plans and each of them is different in terms of the benefit level, copays, and benefits. So the manual stores the information for easy reference.
SMAKA: Do the contracts change often?
BEYER: The contracts with the health plans may change annually;many of them are longstanding and have been in place for years. We usually have a regulatory update to our agreements annually, and then we in turn update our provider agreements so that we can remain compliant with changes at CMS.
SMAKA: In addition to a health plan, who else might sponsor hearing benefits and contract with a network?
BEYER: In addition to health plans, there may be employer groups, benefit sponsors, and affinity groups. Many employers or unions have a hearing aid offering that would improve value for their constituents. Affinity groups could range from a small local group such as an auto club, or church, to a very large national organization such as the HearUSA Hearing Care Program for AARP members.
SMAKA: In general though, health plans don't typically cover hearing aids, correct?
BEYER: Right. Hearing aids traditionally are not a covered benefit through the health insurance plan. The data I have seen places hearing aid coverage at less than 20% of the time, while dental and vision services are covered by the plan over 60% of the time. Many plans model their benefits after Medicare, which of course doesn't cover hearing aids. Because hearing aids are excluded from the typical array of medical benefits, it tends to give the consumer a lesser perception of hearing care as a health issue.
When the consumer is left to seek hearing care on their own, it can be a pretty confusing experience. Do they start with an ENT, a food warehouse, the internet or their local department store? For hearing providers who are part of a network with ties to healthcare and other credible organizations, this is an opportunity. Aligning a hearing program, either a benefit or a discount program with a health plan or other credible group gives it credibility and provides the plan member the trust and confidence to seek the help they need. It creates a pathway for the consumer to follow to a provider office, where they would otherwise face a myriad of choices and not know which one would be the best.
For the health plan, the network brings a lot of value as well. We standardize the delivery system including pricing, warranty, and services provided, so there is consistency across the membership. There's often additional value built into the plan design as well, either a discount or a portion of the hearing aids covered by the plan. The plans don't usually pay for the entire hearing aid purchase, although a few do.
SMAKA: Is a hearing benefit costly for a health plan?
BEYER: Comparatively, hearing aid coverage is not an expensive item for health plans to offer. They're much less expensive for the health plan than dental or vision coverage, for example. Everyone uses dental and vision each year. Not everyone needs hearing aids, and those that do will not be using the benefit every year, since we don't purchase new hearing aids each year. And, there is still a large portion of the population who won't use the hearing aid benefit even if it is free.
No matter how well we do our jobs as audiologists, we know that patients fit with hearing aids need a lot of support, from fitting and fine tuning adjustments to counseling and education. Some patients may be dissatisfied even when we follow best practices and have done everything right. So if there's a complaint some kind of dissatisfaction from a member, having that health plan alliance gives members an extra layer of security and confidence to know that they'll be taken care of. If the member isn't satisfied, they call the health plan. The health plan calls us, and we take care of it. It's an excellent support system for both the health plan and the member. That's the value that an organized network brings to a health plan - they can give their members a secure channel for purchasing hearing aids.
Another thing to consider is that MarkeTrak data tells us that hearing aids are still out of the reach for a very large number of people. They can't afford them;their paychecks are spent taking care of their basic needs - food, medicine and housing. How can we increase utilization of hearing aids? One way is to bring them hearing information via their healthcare communications. Knowing that there are protections backed up by the health plan and that they aren't shopping on their own is a strong selling point for some people. One of the health plans here in Florida recently did focus groups with their members and learned that a hearing aid benefit was more important to their members than dental or vision. Members' feedback included comments that hearing aids are expensive, there are too many reports of bad experiences, and they were tired of trying to figure out where to go on their own. We can also improve utilization by making hearing aids affordable, improving their experiences, and ensuring their satisfaction.
SMAKA: You mentioned that networks have accountability standards. Can you review some of HearUSA's standards of care?
BEYER: We expect best practices of our providers, and they have agreed to provide them. From the state mandated testing requirements to extensive subjective and objective measurements pre and post hearing aid fitting, our protocols are pretty comprehensive. Some of this is basic, and readers will be surprised at what some providers don't do. For example, our providers are required to perform testing in a soundproof booth. While you may think that is the norm, if you visit practices around the country, you will see that it is not the standard everywhere and that there are audiologists that perform hearing tests across the kitchen table, and not for those that are homebound, just as a matter of practice. But if you don't ask the question, or follow up on member complaints or questions, sometimes we don't know these things. Our standards of care follow accepted audiology principles, such as a comprehensive hearing examination, and hearing aid fitting verification using real ear measurements. Follow-up care and rehabilitation are also spelled out.
SMAKA: In terms of both networks and buying groups, can audiologists belong to more than one?
BEYER: If you're a member of a buying group, sometimes they demand exclusivity in order to purchase, and pricing may be such that you will receive better discounts if you make all your purchases from one group. However, there is no reason why people can't belong to multiple networks, unless that agreement has some type of exclusivity. HearUSA does not require exclusivity of its providers, but some networks may.
SMAKA: I guess you just have to keep track of those contracts and make sure that you're adhering to all the guidelines, which might be different among the networks.
BEYER: Yes. Providers should take a few minutes to read through the paperwork and clarify any commitments that they are making in writing. We try to stay in touch with our providers with e-mail and web communications, because it's easy to get lost in the different plans. If questions, don't hesitate to ask.
SMAKA: So then what types of hearing programs would be available through a network for benefit sponsors and their members?
BEYER: Third parties are interested in pricing, service, quality and access. Discounts are always a part of the program, and we try to keep the pricing fair and competitive. The plans also want their membership to receive good service, a high standard of care, and convenient access to a nearby provider. The plan designs can range from simple discounts on hearing aids to full or partial coverage.
We can help benefit sponsors to design an attractive benefit. For example, a plan might say "Well, we're going to cover hearing aids at 100% every two years." What they may not realize is that that could mean anywhere from $2,000 to $12,000 per hearing aid, making it very difficult for them to project their costs. We can educate the plans on utilization patterns and average pricing, and building a more efficient model. In doing that, we can help to reach more people who need help. For example, the average price of a hearing aid may be $1,600 and we may discount it to $1,500. Now, instead of having one member use up $12,000, they can help six more people with the same investment.
As I mentioned, there's full coverage, and partial coverage programs as well. We can enhance the delivery system by adding free batteries or additional warranty. The Hearing Care Program for AARP members is loaded with additional features and member protections, addressing everything from the initial appointment to the follow-up care, educational support, and free batteries for three years, and extended warranties.
So depending on the benefit sponsor and what they're looking to do, we can develop different programs that will be attractive to their membership and help them to promote the value of hearing care.
SMAKA: Cindy, can we talk about a network from the standpoint of the audiologist? What benefits do they get for joining a network?
BEYER: One of the most compelling benefits is that HearUSA and the program sponsor make the program visible to the plan's membership. The plan will promote the value of hearing care and our providers. When a member is told to contact HearUSA for information or an appointment, that member is directed into one of our provider locations. By nature of the audiologist's affiliation with us, they're going to see those appointments on their schedule. The plan affiliation gives the provider a bit more credibility, higher visibility, and aligns them in a process that's very clear to the member while also being very educational in nature. We invest marketing dollars into these programs so that our providers will benefit. We market our providers' practices through member provider directories and through benefit sponsors' Internet portals. We generate marketing material, coordinate claims and facilitate benefit payments. The other piece to this is that network participation can signal a provider's qualifications.
View the TV ad for the AARP Hearing Care Program provided by HearUSA here.
As a doctorate-level profession, we need to be committed to best practices. We need to focus on the consumer and to hold ourselves accountable. If we want to see our practices grow and improve access to hearing care then we need to be consumer responsive - give the consumer what they want and what they need. How do we get that message across? We can align ourselves with an accredited network that stands for the same things we believe in.
SMAKA: What exactly does that mean, accredited, and how does that distinguish the HearUSA network?
BEYER: Independent accreditation means that an organization that specializes in quality healthcare evaluates your company from top to bottom and compares you against existing healthcare standings. HearUSA was initially independently accredited by JCAHO, the Joint Commission on the Accreditation of Healthcare Organizations, for ten years. Then JCAHO shifted their accreditation focus to ambulatory centers and hospitals and no longer provided accreditation for networks.
So we looked at the other options. We have now been accredited by URAC for the last two years, and they specialize in health networks. We are the only accredited hearing care network. Accreditation is an investment that we make in the foundation of the company. It demonstrates our commitment to accountability and quality. It means willingness for us to say, "We want to do an outstanding job. We want to be the best we can be. "
URAC evaluates us across nearly 100 standards that address our performance relative to network management, human resources, training programs, IT security, company organization and leadership, consumer protections and credentialing. Credentialing is actually very important because is places a high level of scrutiny on the qualifications and experience of the provider. This is a formal process where we look at our providers individually, and verify their resumes, backgrounds, insurance status, license status, etc. We need to verify the information they provide with insurance companies and licensing boards, as well as query national databases to look for sanctions and disciplinary actions.
SMAKA: So the credentialing is something that every professional would go through if they were to apply to join the HearUSA network, correct?
BEYER: Yes. It is very structured and each application is reviewed and processed before going to committee. A committee of five approves or rejects each applicant, and then we go through that process again three years later. If we are putting our name with theirs, then we want to know that we are representing each other in a positive light with integrity.
SMAKA: Cindy, I learned a lot today about the complex world of health plans, networks and buying groups and me thank you for sitting down and speaking with me.
BEYER: Thank you for having me, Carolyn.
SMAKA: Where can we direct readers for more information on these topics?
BEYER: Readers can visit our website, www.hearusa.net, or contact us at (800) 333-3389.