Government Run Health Care – Possible Consequences For Cochlear Implants?

By Eric Sherman

The following was a post I saw online from a CI parent, from another country, which has universal health care and it got me wondering what could be the possible consequences for cochlear implant users if a universal health care system was implemented in the United States:

“Our government funded system holds one contract only with another implant company - therefore blocking AB from our market. No insurance cover for implants, so its government funding or private. We implanted AB because we had to pay private. I know our country blocks users from accessing some clinics due to wearing AB and not Cochlear. A lot of politics at play here.”

Our recent attempt at using Medi-Cal to try to purchase CI equipment really opened our eyes to how one of our government’s health care programs runs in this country. 

When needing to order headpieces, we were told that it could take up to 90 days to receive approval from Medi-Cal.  Around the 90^th day, we were informed we needed a case number to receive an authorization.  I spent additional weeks trying to find out a case number.  When I finally reached the Nurse Case Manager, she said she had no record of my son ever receiving a cochlear implant.  My son has been in the system for 11 years.

My son qualified for Medi-Cal because of his severe hearing loss and the program was used as a secondary insurance to receive his cochlear implants.

 

The nurse asked for a recent audiology report, so we sent our son’s last audiogram.  The nurse then informed us the audiology report was not acceptable and that they need to verify my son is deaf and has cochlear implants at one their approved facilities.   

According to the Board of Audiology, there are 34 Audiologists in the United States who hold a Cochlear Implant Specialty Certification.  Our son’s audiologist is one of them.  A simple phone call, from the case nurse to our audiologist, probably would have been enough to provide confirmation that my son was deaf and had cochlear implants.

To receive any benefits under Medi-Cal, you need to see a Medi-Cal provider.  There are only two Medi-Cal provider locations in Los Angeles where an audiologist could conduct an audiogram to confirm our son’s diagnosis.   UCLA was one of the facilities, so the Case Nurse set up an appointment for us. 

The UCLA audiologist was surprised they were being asked to do an audiogram on a CI child to confirm they had no hearing.  They happily did the test wrote up the report and submitted it.  We got a case number submitted it to purchase the headpieces and to this day we still don’t know if Medi-Cal paid for any portion of the headpieces…and it has been almost a year.

Our experience and the comment from someone living with a government run single payer system made me wonder what would happen here in the U.S. if single payer government run health care system was implemented:

• Would the government drive down the cost for cochlear implants that only one manufacturer could afford to deliver products to meet government price requirements?
• Could one manufacturer lobby for exclusivity for their devices?
• Would there be enough ENTs to choose from to do the surgery in a timely matter that would accept the government’s reimbursement rates?
• Would there be enough audiologists to choose from who accept the government’s reimbursement rates to activate and service cochlear implants?
• Would a universal health care system inspire new innovations by manufacturers if they already had a secured government contract for their device?
• Would a child miss valuable language development time waiting for an approval to receive a cochlear implant or even getting the needed equipment in a timely fashion?
• Would we be sacrificing quality care for costs?

These are just some important questions to consider when examining a possible government-run health care system.   

About Ci Wear

Ci Wear shirts are used as rash guard/swim shirt in the water or as a high-performance shirt on land. The shirt features raglan sleeves and flatlock stitching for added comfort and flexibility. The shirts are made in the USA and sell directly to consumers via online store. Available in adult and youth sizes. For more information visit www.ciwear.com.

#singlepayer #cochlearimplant #insurance 

Do Insurance Companies Determine Unreasonable Rates For Cochlear Implant Equipment?

By Eric Sherman

When your cochlear implant equipment is out of manufacturer’s warranty period and you need a new sound cable, headpiece (coil) or processor, often people will go through their health insurance to help cover part of the cost.  Not all health insurance is the same, so be aware as your insurance company might reimburse you for less than you expect. This was the case with us when we purchased a CI sound cable for $125.00 and the insurance reimbursed us $5.81, less than 10% of the cost.

 

Cochlear Implant Sound Cord

After receiving our reimbursement check and Explanation of Benefits (EOB), we noticed the “Allowable Amount” (the amount the insurance company will pay for service or medical equipment) was substantially less than the cost of the equipment ($125.00 compared to their allowable amount of $11.62).

When inquiring about the allowable amount and how it was derived, the insurance company’s own definitions, terminologies and explanation were as confusing, ambiguous and misleading as credit card offers you receive in the mail.  Under “medical supplies, equipment and footwear benefits” in our plan it stated our responsibility is “all charges in excess of 50% of the Negotiated Fee Rates,” for non-participating providers.  The negotiated fee rate is the rate negotiated for in-network providers and is synonymous with “allowable amounts.”   Our implant manufacturer is not a participating provider, but we received an in-network provider waiver, meaning we would receive the in-network rate (60% coverage based on our plan).

Here is the problem with cochlear implant equipment; it is proprietary to each manufacturer’s device.  Parts cannot be mixed and matched between manufacturers.  Finding a compatible sound cable at the cost of $11.62 is not possible.  In our grievance filed with state regulators, we argued this point and requested the insurance company explain their methodology in how they derived at $11.36, in this instance, to determine their allowable amount.

Based on the definition outlined in our policy, we reasonably believed that the insurance company would cover 60% of the cost of the sound cord.  The insurance company responded to our inquiry and grievance describing five different methods of determining allowable amounts and none of it made sense in relationship to our claim. In some instances, their explanation directly contradicted what was outlined in our policy.  Eventually, the insurance company claimed the amount was determined by a “customary and reasonable rate of reimbursement and not at billed charges.”

A "customary and reasonable" is a term used by insurance companies to cap their exposure on certain medical equipment and procedures. Paying less than 10% of the billed amount didn’t seem to be reasonable.   The insurance company refused to divulge the methodology used to determine what was customary and reasonable and thus settled on the rate of $11.62.  Under this terminology, insurance companies decide the rate they will pay. 

In the end, state regulators didn’t have the legal authority to compel the insurance company to reveal how they came up with their rates. An adjustment was made to our claim and the rationale behind the adjustment was equally confusing.  We were reimbursed more on our claim, but the amount was substantially less than what was billed.  

Clearly, the power in the health care industry lies with the insurance companies and not the consumer. Right now is open enrollment for health care insurance (it’s the law, you must have health insurance).  If you are looking for a new health care plan, you may want to contact the insurance provider you’re considering to find out their coverage on your cochlear implant equipment.  (Here are links to billing codes for different cochlear implant manufacturers Advanced Bionics, Cochlear, Med El).

Final thought, be an informed voter when it comes to your health care.  Avoid the temptation of negative ads and political bias.  Unfortunately, in our state, the voters missed an opportunity to gain more control over their health care.  The insurance companies ran a huge negative ad campaign with no opposition which helped defeat a health care proposition.  The bill would have helped make health care costs more transparent.

More about Ci Wear
Ci Wear is a patent pending shirt designed for cochlear implant processors and other listening device.  Use as an exercise shirt, rash guard or swim shirt during sports activities. The shirts have pockets that add a layer of security to your device. Made in the USA and sells direct to consumers via online store.  Shop at www.Ciwear.com. 

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