Representatives from the Academy of Doctors of Audiology (ADA) met with representatives from the Blue Cross Blue Shield (BCBS) Federal Employee Plan (FEP) on February 20, 2024 to gain insight on the 2024 FEP hearing aid prior authorization process and medical policies and share our experiences and thoughts on creation and implementation of these changes. ADA shared many of the issues that we have encountered and shared the experiences being reported by audiologists and FEP members.
We highlighted several topics during our call:
Gaining a better understanding of why FEP instituted the prior authorization process and medical policy.
Per the FEP representatives, these policies were created and implemented due to overutilization on numerous fronts (manufacturers, clinics, and providers). BCBS FEP wants to ensure that prescription hearing aids are being initially dispensed and replaced, when medically necessary, on hard of hearing individuals who can benefit from amplification. These policies were created to better control and ensure that this goal is met.
The 40dBHL coverage limitation.
ADA lobbied to lower the coverage limit to 26dBHL, consistent with Tricare, Anthem, and many other commercial and state health plans. We provided them with peer reviewed literature to support this change in coverage limitations.
FEP clearly stated that provider can appeal prior authorization denials for hearing losses of less than 40dBHL and that FEP members, with hearing losses of less than 40dB HL who currently wear hearing aids and are seeking a replacement, should be “grandfathered” into coverage for replacement devices, as long as their current hearing aid is out of warranty, unrepairable, and/or no longer audiologically appropriate (as outlined in the medical policy for the requirements of replacement hearing aids).
The requirements of a prescription.
FEP wants to ensure that they are covering prescription hearing aids because they do not offer coverage of over-the-counter devices.
FEP clearly indicated that licensed providers can provide prescriptions for hearing aids as allowed by their scope of practice.
The requirements of prescription of an FDA “approved” prescription device.
ADA highlighted the realities of the FDA hearing aid “approval”/registration processes and reported the challenges of requiring providers to prove that a specific make and model of hearing aid is FDA “approved”.
ADA advocated for significant changes to this aspect of the prior authorization process and clarity, from FEP, as to what specific site prescribing providers must access when proof of FDA “approval” is requested.
Initial prior authorization submission process.
ADA outlined the difficulties that exist in the initial prior authorization processes in many parts of the United States. We highlighted the significant differences from state to state in the implementation of these policies and the difficulties being experienced by many providers.
ADA advocated for a singular prior authorization form for all hearing aid prior authorization requests and a specific, singular point of submission (portal link and/or clearly delineated fax number) in each state and territory. We even supplied a draft prior authorization form for their review and consideration.
Peer to peer review/appeal of prior authorization denials.
ADA expressed concerns with the current appeal/peer to peer review process and reported many immediate denials for hearing losses of 40dBHL or less, despite the fact that the medical policy clearly indicates that consideration will be given for coverage for losses of less than 40dBHL. We also expressed concerns about the qualifications of reviewers, in many instances, to provide final determinations on hearing aid coverage.
FEP indicated that they supply FEP plans with a proprietary manual for use in the appeal process that they hope standardizes the coverage determination processes. They stated that providers can request a like specialty review of a prior authorization denial. This will better ensure that the reviewing provider is more closely related to audiology/hearing aid dispensing. They cannot though guarantee that all reviews will be conducted by an audiologist.
FEP reiterated that, if a provider is denied in the peer to peer, prior authorization appeal process, that the member (patient) has the ability to submit their own coverage appeal to FEP. This link is available on FEP Blue websites.
Out of network coverage of hearing aids.
ADA requested clarification of hearing aid coverage and benefits for FEP Standard, Basic and BlueFocus members. Per FEP, Standard and Basic FEP plan members have coverage for prior authorized hearing aids and related services from both in (participating) and out (non-participating) BCBS providers. BlueFocus members do not have funded hearing aid benefits.
Conclusion
FEP continues to collect information and feedback from all stakeholders, including members. They plan to continue to review and evaluate this policies and processes, based upon this feedback. Changes may be made to the prior authorization process and medical coverage policies.
ADA will continue to advocate for operational changes to this program and its policies and processes. We will also continue to provide guidance to our members as the program evolves.
Recommendations in the Interim
- Follow the medical policy guidance (https://www.fepblue.org/-/media/PDFs/Medical-Policies/2024/January/UM-Guidelines/FEP-UM-Guideline-005-Hearing-Aids-2024-benefit-update-_PMPC-correction.pdf).
- For initiating the prior authorization process, use your Availity or BCBS portal, use the pre-certification contact phone number and/or fax number for your state FEP plan, or have your office or the FEP member contact the number on their insurance card.
- For prior authorization requests, you must include the results of a comprehensive audiogram (air conduction, bone conduction, speech reception threshold, and speech discrimination). We have also found that the following information has been valuable in both initial prior authorization request and appeals:
- All audiometric test results required by FEP and the State.
- Three and four frequency pure-tone average.
- Results of medically necessary audiometric testing and otoscopy.
- Results from a standardized inventories (i.e. HHI, COSI, SAC, etc.)
- Speech in noise results.
- Unaided real ear.
- Results of any basic health screenings (cognitive, APD, speech/language, dexterity, mobile proficiency, falls).
- Findings from patient interview regarding audiologic and communication needs.
- Copies of any medical referrals/orders/findings/evaluations.
- Medical clearance/waiver, if required by a State or FDA (17 years and under).
- Prescription for make, model and style of hearing aid being prescribed (as allowed).
- Documentation of medical necessity for the type, style, and features of hearing aid being prescribed, including peer reviewed research supporting necessity.
- For appeals, request a like specialty review and clearly document medical necessity as outlined above.
When they ask for proof of FDA approval note that the FDA site that illustrates that a manufacturer has approval to supply air conduction, prescription hearing aids (https://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm) and FDA site that lists FDA registered makes and models of hearing aid (https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRL/rl.cfm).
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