Kids Are Hurt by State Policy on Hearing Aids

A dilemma exists in the provision of speech and hearing services to low-income children covered under the California Children’s Services, or CCS, and Medi-Cal programs. While the number of children requiring such services (diagnostic evaluations, hearing aids, therapy and associated services) is experiencing a dramatic increase, the number of audiologists and speech pathologists able and willing to provide these services is declining.

The heart of the problem lies in the mechanisms for authorizations, as well as the level and timelines of reimbursement for these services.

CCS provides reimbursement for hearing evaluations, hearing aids, audiology services, speech and language evaluations and speech therapy. Unfortunately, there has not been an increase in reimbursement rates for many years, even as costs for devices (hearing aids, batteries, ear molds, etc.) have risen.

As a result, the cost of providing services far exceeds the reimbursement. In our clinic, the Providence Speech and Hearing Clinic in Orange, we lose a minimum of $8 per hour for every Medi-Cal and CCS client we see.

Not only have the low reimbursement rates negatively affected audiologists’ decisions to continue as providers, but delay and denial in payments have also become a significant issue. They frequently run 120 to 180 days beyond the date of service. The required paperwork is onerous, with frequent denials made for trivial reasons. Additionally, even when a service is authorized in writing by CCS, it is possible that payment may be denied later because of a lapse in coverage.

For these reasons, our nonprofit clinic contracts with a third-party claims processor for all CCS claims, giving up 9% of collections. This is the only outside processor that we use, and it is for the third-party that pays the least.

The paperwork is a burden disproportionate to both the reimbursement rates and that required by other managed-health-care entities. To provide services to a child covered by CCS, we must get individual written authorizations for services at each step.

Lapses or delays in necessary services frequently result from this fragmented process. As an example, recently in the clinic I saw a boy who has a broken hearing aid; it took nearly five weeks to get approval to send it out for repair. It will take another two to three for the repair to be completed, leaving this child without his hearing aid for a long time.

This situation shows every sign of becoming more dire. First, increasing numbers of audiologists in private practice are no longer accepting these children for services. Second, the number of children requiring these services is growing.

Third, and most crucial, because of recent state legislation, the California Newborn Hearing Screening Program will offer hearing screening to all newborns born in CCS-approved hospitals. While the aim of this legislation is exciting--earlier diagnosis and treatment for infants’ hearing impairment--the practical consequence is that an increasing number of infants and young children who are covered by CCS will require evaluation and treatment by audiologists and speech pathologists.

Providence’s board of directors raises nearly $300,000 each year to help underwrite services to low-income patients. Even with this generous contribution, the number of children referred for services far surpasses our capacity. Because of inadequate reimbursement and inefficiency in processing, Providence in essence subsidizes the state of California. Since the state has made a commitment to providing these services, it is time that it also take responsibility for making sure that there are enough providers to examine these children, as well as sufficient reimbursement and a streamlined process for authorization and follow-up.

What can be done? A committee of family members, providers and health-care administrators could be convened to examine the system from top to bottom.

It should identify strengths and weaknesses and propose changes in procedures and reimbursement to reflect reality, that is, higher costs, families whose primary language is not English and children with multiple handicaps who need case coordination.

There is no question that increased funding is required, both for administration and for increased reimbursement. I believe, however, that with improved systems and payments, more providers will be willing to serve the children now being underserved and ultimately health-care and education savings will be realized.

In no way do my comments reflect lack of satisfaction with the personnel at CCS, who are caring professionals. No one wants to see low-income children with hearing and speech disorders go without diagnosis and treatment.

If services are not available and if restructuring the program and increasing reimbursement cannot (or will not) be accomplished, then it seems that the only solution is to revise the program to decrease the number of children who are eligible.

The alternative is to continue a program that is overwhelmed, overburdened and archaic.