Maryland audiologist fights Medicare’s ban on private-pay care
Medicare pays Dr. Alicia Spoor $29.21 for an hourlong comprehensive hearing evaluation. Keeping her Maryland audiology practice running costs about $235 an hour—and that’s just to break even.
Dr. Spoor is an audiologist, a doctoral-level clinician who diagnoses and treats disorders of hearing and balance. At Designer Audiology, her independent practice in Highland, Maryland, she tests hearing, fits hearing aids, programs cochlear implants, treats tinnitus, removes earwax, and teaches musicians how to protect their ears.
Some of her Medicare patients would rather contract with her directly, but federal law prohibits her from taking their money.
Why she became an audiologist
Dr. Spoor has lived with tinnitus most of her life and hearing loss runs in her family—which inspired her to become an audiologist. She earned her Doctor of Audiology at Gallaudet University in Washington, DC, completed her externship at Mayo Clinic in Arizona, and has practiced in Maryland since 2007.
Her career began in another audiologist’s office, where she witnessed the industry standard practice for selling hearing aids: one bundled, up-front price for every patient, regardless of how much care actually was required.
Her desire to do things differently—charge patients only for the services they need—inspired her to open her own practice.
Bound by Medicare
Because hearing loss is more common in older adults, many of Dr. Spoor’s patients are on Medicare. Their care is bound by the program’s rules.
Every service she offers starts with a diagnostic evaluation, the necessary first step before any treatment. That evaluation is the one service audiologists must provide through Medicare. For most actual treatment services, patients pay Dr. Spoor directly, because Medicare usually won’t cover them.
Before her office can even book an appointment with a Medicare patient, the front desk has to triage them with a series of questions: Is the hearing problem acute? Is there pain, drainage, or dizziness? Has the patient fallen in the past year? When was their hearing last tested, and who ordered it?
The answers determine whether the patient first needs a physician’s order.
“You’re trying to explain this to somebody who is dizzy and they want to come in as quickly as possible, but now you have to get an order and so it’s three more visits,” Dr. Spoor explains.
Patients often don’t understand the rule, and neither do their doctors. Dr. Spoor’s office gets about one call a day from a physician’s office asking why a Medicare patient needs an order for a hearing test.
A cochlear implant patient may need to see her 10 times in the first year after surgery. Medicare requires a new order for each visit.
Patients also fill out a form at every visit acknowledging that Medicare might not cover their service—and are often surprised at the end of the visit upon discovering their out-of-pocket cost. That’s because whether Medicare covers a test depends on why it’s performed, which often isn’t clear until the test is done.
For Dr. Spoor, Medicare’s rules mean guessing before each test whether Medicare will cover it. A wrong guess can mean a denied claim, a repayment demand, or an accusation of improper billing, all over a payment of about $30.
The only way out would be to turn away all Medicare beneficiaries—precisely the population that needs her the most.
What it costs her practice
The loss her practice absorbs on the many hearing evaluations it performs—recall the measly $29.21 Medicare reimbursement—means Dr. Spoor must charge private-pay clients two to four times what she otherwise would for treatment, hearing aids, tinnitus devices, and hearing protection.
She opened her practice so patients wouldn’t subsidize each other’s care, but Medicare forces her to do exactly that.
“Medicare is making it harder for me to be fair to all those patients,” she says. “I’m actively punishing my patients that are coming in for treatment or buying devices or paying privately when they can because Medicare is forcing me to do this.”
The shortfall also limits her ability to invest in her business; she can’t readily upgrade equipment or pay her staff as competitively as she’d like. The profession as a whole is feeling the strain, and it’s struggling to attract new audiologists. Her bankers and accountants ask her why she keeps working with Medicare at all. “I don’t have a choice,” she says.
“We’re losing bright kids to other professions at a time when you’ve got 10,000 patients a day coming into the Medicare system,” says Stephanie Czuhajewski, executive director of the Academy of Doctors of Audiology.
Independent audiology practices across the country are selling to hearing aid manufacturers and private equity firms, moving into hospital systems, or closing. There are about 14,200 practicing audiologists in the U.S., and their numbers aren’t keeping pace with the growing number of Americans aging into Medicare. The shortage will be felt most acutely in rural communities with few providers.
Everyone else can opt out
Federal law permits most healthcare providers to opt out of Medicare, meaning the patient and the provider can contract with each other directly. That list includes physicians, optometrists, nurse practitioners, physician assistants, clinical psychologists, registered dietitians, marriage and family therapists, and mental health counselors. For some reason, audiologists are left off that list, as are physical therapists.
The contrast with optometrists is especially stark. Optometrists and audiologists complete similar doctoral training and are licensed in every state, and each care for a single sense: one the eyes, the other the ears. The same sentence of the Medicare statute even excludes both eyeglasses and hearing aids from coverage. Yet an optometrist can opt out and let a Medicare patient pay privately for an eye exam. An audiologist can’t do the same for a hearing exam.
As a result, audiology practices are struggling to compete with other, less burdensome options. Hearing aid dispensers—who, in most states, need only a high school diploma and on-the-job training—can test a Medicare patient’s hearing and deal with them privately, with no doctor’s order and no Medicare paperwork, offering a much smoother experience for patients.
Fighting back
On October 14, Dr. Spoor, Austin audiologist Dr. Jill Davis, and the Academy of Doctors of Audiology filed a federal lawsuit with the help of Pacific Legal Foundation. They argue that the exclusion interferes with audiologists’ right to earn a living and that the government has no rational reason to let physicians and nurse practitioners contract with willing patients while denying audiologists the same freedom.
If she could opt out, Dr. Spoor would reset her fees to achieve the vision she’s always wanted for her practice: one where every patient pays a fair price for their care. All she’s asking for in court is the same choice nearly every provider already has.
