I’ve just gotten off the phone with Oxford and confirmed what I originally believed: my plan includes unlimited coverage for hearing aids, including repair and replacement, subject only to my annual deductible (already met) and a $100 copay provided that hearing aids are purchased through an in-network provider. My question is therefore how to find out whether my audiologist is in-network for hearing aid purchases. I know that she is in-network for medical; Oxford has had no problem paying for my testing or my visits. But it is my understanding that some or perhaps many audiologists who are participating providers for medical services are not under contract for hearing aids because they can’t make a profit at contracted rates. The representative I spoke to on the phone was singularly unhelpful, directing me to the website and saying to search under “audiologists.”
Does anyone have experience purchasing hearing aids through Oxford? How should I go about verifying that my hearing aid provider is in-network?
With Blue Cross Blue Shield, they are able to tell you who is in or out of network. I believe Oxford should know the answer as they are the ones that sign a contact with the practitioner to be in network.
The problem is knowing whether they are in-network for hearing aids, or just for medical services. The representative I talked to, at least, did not understand the difference.
I finally found a local provider willing to bill Oxford, so I went to their office and sat down with the secretary to talk insurance. She spent an hour and a half on speaker phone with Oxford interrogating them about benefits, billing procedures, reimbursements, etc. and getting conflicting and incomplete information. In the end, the doctor herself got involved and asked a bunch of good questions and lodged complaints about the incorrect and conflicting information we were getting.
Here’s the upshot: I have in-network coverage subject to a limit of $5,000 per hearing-affected ear per year, total limit $10,000, subject to my overall deductible (already met) and a $100 copay.
The audiologist needs to submit an itemized, unbundled claim, separating the dispensing fee from the cost of the hearing aids and including the manufacturer’s invoice for the aids. They will reimburse the full cost of the aids, so she won’t get screwed on that, but the dispensing fee will be reimbursed based on some sort of third-party formulary. Subsequent visits for repairs, adjustments, etc., should be billed separately; they won’t pay upfront for future services as is the common practice. This way, incidentally, such future visits will be subject to copays and yearly deductibles.
Overall, it’s a very good deal for me since I will get a set of premium aids for $100, but there’s a chance my audiologist will be seriously under-compensated for her professional services. Certainly she will make no profit on the sale of the aids themselves. She may be able to make up for it over time by billing separately for services that would normally be incorporated into the cost of the aids.
I was impressed by the amount of time they would take getting these details hammered out for me even though I wasn’t yet even a patient. Even though this audiologist’s location and hours are much less convenient to me, she and her staff have won me over with their knowledge and tenacity. I have an appointment for 3/23 to review my , take measurements, and decide on an initial aid to trial, and a dispensing appointment for 4/9. It’s a little longer than I had hoped to wait, but I think it’s worth doing right. I want to have all the insurance arrangements taken care of before she even places the order.
Well, my claim was processed and Oxford paid $2,500 dollars per aid, which they say is the allowed amount. They’ve cut my audi a check for $4,900—the allowed amount minus my $100 deductible. According to the explanation of the code, this “is an agreed rate.” I don’t think I should have to pay the $990 difference between the billed amount and the allowed amount, but I’ll talk to my audi at my follow-up appointment on Thursday. If there’s an issue, I’ll follow up with Oxford; I’m supposed to have a $5,000 per ear, $10,000 total maximum benefit.
this is rather typical in insurance plans to pay a ‘usual and customary’ amount or allowed amount. the billed amount is whatever the dispenser charges. sometimes the dispenser will accept the allowed amount and sometimes not. the maximum amount rarely reflects the amount the insurance company will pay on any device or procedure. the maximum amount generally reflects the maximum it will pay for all cumulative devices, procedures, etc. in a specific period of time.
this is rather typical in insurance plans to pay a ‘usual and customary’ amount or allowed amount. the billed amount is whatever the dispenser charges. sometimes the dispenser will accept the allowed amount and sometimes not. the maximum amount rarely reflects the amount the insurance company will pay on any device or procedure. the maximum amount generally reflects the maximum it will pay for all cumulative devices, procedures, etc. in a specific period of time.
I apologize if I gave you the impression that I am clueless about how insurance works. As I thought I made clear, I understand that they are paying at their allowed amount, which, as an in-network provider, my audiologist should accept. If there is an issue, I will follow up with Oxford.
I apologize if I gave you the impression that I am clueless about how insurance works. As I thought I made clear, I understand that they are paying at their allowed amount, which, as an in-network provider, my audiologist should accept. If there is an issue, I will follow up with Oxford.
is you plan an HMO or PPO? if it is a PPO, i have seen doctors charge more than the allowed payment.
I think his point is that if the provider chooses to participate in the insurance’s “in-network” program, then they should have to accept the rate the insurance pays. It is sort of fraudulent to claim to be “in-network” and then try to gouge the patient for more money. If a provider is isn’t happy with the rates the insurance company pays, then they should not be listed as participating and in-network. You might want to file a complaint with your AG’s office.
Woah, we’re getting way ahead of ourselves here. I don’t know that my audiologist won’t accept Oxford’s allowed amount as full payment. I haven’t talked to her about it, nor have I received a bill for the balance from her. It is my understanding that, by contract and by Connecticut state law, in-network providers are required to accept the allowed amount as full payment.
And it’s not like she’s going to be losing money on them. It is my understanding from my research that the aids probably cost her around $3,400, which leaves around $1,600 to cover professional services and a small profit.
Yes, it is. I know full well that I am very fortunate. My health insurance changed to Oxford in December after 11 years with Anthem BCBS. Prior to that time I had absolutely no coverage for hearing aids.
I’ve said a lot of negative things about Oxford, and I stand by them; Oxford’s customer service is poor, their customer service reps (note: not their nurse line staff) unknowledgeable, and their promptness with payment dismal. Their drug formulary is also very stingy. But in this one area they’ve really done well by me: I got not only adequate but truly top-of-the-line aids and they paid for nearly everything. I am very pleased.
It’s beyond me how inurance can refuse to pay for hearing aids for those who need them. Not being able to hear is a horrible thing and hearing aids are very costly and few can afford them with insurance.
sabrin, its not insurance companies that pay for an individual’s hearing aids, its the other policy holders. if one in twenty people needed a hearing aid, the aids lasted five years, and the average cost was $5000 like this thread, then every policy holder would have to pay an extra $4.17 per month or $50 per year to pay for the one person’s hearing aid. i assumed only 5% of the population. some say 20% of the population has hearing issues. so now the cost to each individual would be $16.68 per month. i acknowledge these figures might be a little high but the point is nothing is free and insurance benefits for one come out of the pocket of several others.
it is proven that the more insurance pays for a medical procedure the higher the cost because there isn’t someone pushing back to lower the cost.
in addition, while it is nice if insurance pays for all of our specific medical needs it is really our friends, neighbors and relatives who pay most of our cost. it is the responsibility of ourselves and our family to save money for some of our individual expenses.
You can’t take anything for granted with health insurance or hospital billing. It is always a battle when you have a need. And, it isn’t being fixed. All parties seem to be happy to confuse, misbill and insist. I had just major medical and a heavy upfront on my part. All but once I finally got it for the price of the deductable. On the one, I told them to take me to court and they didn’t. But the hospital billing department called for years. It a broken system and hearing aids, where covered, probably among the least egregious or understandable.
Oh, if you are in a hospital, have your doctor prescribe any normal meds you might need. You wouldn’t believe what an aspirin can go for. Such request not from the doctor get patient billed.
You can’t take anything for granted with health insurance or hospital billing. It is always a battle when you have a need. And, it isn’t being fixed. All parties seem to be happy to confuse, misbill and insist. I had just major medical and a heavy upfront on my part. All but once I finally got it for the price of the deductable. On the one, I told them to take me to court and they didn’t. But the hospital billing department called for years. It a broken system and hearing aids, where covered, probably among the least egregious or understandable.
Oh, if you are in a hospital, have your doctor prescribe any normal meds you might need. You wouldn’t believe what an aspirin can go for. Such request not from the doctor get patient billed.
ken,
you are right about it not being fixed. private insurance has not been motivated to fix it. the govt. while fixing a few things messes up many more. the medical industry well i could say many things about it but i won’t.
its unfortunate there are too many differing interests with their own concerns working towards different goals which makes it almost impossible to reach real conclusions that are not wasteful and inefficient.
Well, you know… Why should everyone have to pay for someone else’s cancer treatments then? How about transplant patients? Only a small percentage of the population needs a transplant. These things are far more expensive than hearing aids. That is basically what insurance is. It’s a shared pool of money that is used for expenses. What costs more? That cancer patient receiving over a hundred thousand dollars of treatments, medication, and care or someone with hearing aids… most people probably don’t need them until after 50 or 60 and are only allowed replacements every 4 years of so covering a limited amount like $1,500 per hearing aid… so on average, based on life expectancy, that might be 4-5 set of hearing aids in a lifetime for most people… That’s $15,000 over a 20 year period compared to far more for people with expensive health issues and conditions. If you don’t like being part of the share pool of costs, then don’t buy insurance. You can “self-insure” and save your own money for your own health care and just pray you don’t have something catastrophic happen. Oh, wait… thanks to the fascists running the government, you’re not allowed to self-insurance anymore unless you want to pay a tax penalty… Thanks obamacare!
Well, you know… Why should everyone have to pay for someone else’s cancer treatments then? They are far more expensive than hearing aids. That is basically what insurance is. It’s a shared pool of money that is used but expenses. What costs more? That cancer patient receiving over a hundred thousand dollars of treatments, medication, and care or someone with hearing aids… most people probably don’t need them until after 50 or 60 and are only allowed replacements every 4 years of so covering a limited amount like $1,500 per hearing aid… so on average, based on life expectancy, that might be 4-5 set of hearing aids in a lifetime for most people… That’s $15,000 compared to far more for people with health issues.
sabrin,
i get your point. its not just what insurance covers but also the cost. when obamacare was enacted, many people have revolted and demanded that the govt. stop it. they feel that their insurance cost has gone up and they don’t like it. almost everyone in the industry knew that many of the current policies would go up because the type of coverage, the range of coverage, and the items covered all were changed. most people don’t realize that their items covered increased but also the people covered increased and the limits increased. but the public is still angry. because of the changes in the laws, insurance companies are forced to offer more coverage to more people with a restricted profit but the public still hates it.
insurance was originally designed to help in unanticipated situations or to protect people from major financial loss. cancer is much more costly than hearing aids.
it might be nice if insurance or the govt paid for every medical necessity but are we willing to pay the cost? i don’t think so in today’s political environment.
the shared pool of money you talk about is allocated by insurance specialists using the law of large numbers to determine how many people will get what disease or accident and determine how large the pool needs to be. then costs, investment income and profits are factored in. then, based on age and location each person’s cost is determined. so, to pay for hearing aids this cost has to be factored in before the premiums are paid.
you could also make the point about all health insurance paying for glasses or dentist or other things. :o
NW Indiana