Marketing and Financial Aspects

Twenty dollars income with nineteen dollars expense equals happiness; nineteen dollars 
income with twenty dollars expense equals misery.” This is a line from the classic Charles Dickens novel David Copperfield that sums it up. It is really that simple.

Chapter Eight in my book is a fairly dry look at the financial aspects of managing a successful balance clinic. It can be broken down into two sections: 1. getting people in the door, and 2. getting paid for the work you do.

A third area not discussed in my book is the last variable that will determine profitability; expense. I have had many people call me over the years for advice in setting up a balance clinic, and many seem to get stuck on the same subject, equipment expense. In reality, the cost of equipment is not a major expense when compared to other ongoing expenses such as staff salaries, rent, taxes and so on. Keep in mind that all those other expenses do not result in a hard asset. Once the money is spent, it is gone. A well researched, maintained and utilized piece of equipment will more than pay for itself. At worst, the equipment can be sold and some of the investment recouped. That can not be said for those other expenses.

Marketing is a bit of a sore spot for many Audiologists. Because hearing aid dispensing is such a large part of a general Audiology practice, it is impossible to avoid the retail aspect of this business. We do not advertise our balance clinic to the public. In fact, we do not accept patients for balance and dizziness complaints unless they are directly referred by another physician. It is not unusual to find a patient that has dizziness as a result of a medical problem or from a medication. It is imperative that the patient have access to a primary care physician, because our recommendation may be to “Go back to your doctor and discuss our findings.”

Our approach to marketing has been through physician education. The “Dizziness and Balance Disorders” booklet available from Micromedical technologies was designed to educate the local primary care doctors in our region. I also do continuing education programs for the local hospitals whenever invited. Word of mouth is very important. Everyone knows someone that is dizzy. We have many patients that ask their PCP to refer them to us because a friend or family member had a positive experience.

There are plenty of books on marketing, but I think if you can follow these three simple rules, 
you will succeed:

  1. Be competent
  2. Treat people respectfully and with compassion
  3. Get results
Financial Aspects primarily covers getting paid. Since most health care is covered by a third party, it is essential to understand the (intentionally?) confusing rules of proper coding and billing. The article follwing this blurb was written as a result of my frustration in getting any clear guidance from Medicare on how to properly bill for vestibular testing. The applicable codes are listed in my book. I have recently been working with the coding and reimbursement committee of the Academy of Audiology to update and clarify some codes. Unfortunately, AAA has no direct input when it comes to coding. The CPT codes are determined by the American Medical Association. When a procedure becomes widely used, and is proven effective in peer reviewed journal articles, the AMA will designate a 5 digit procedure code. Just last year, new codes were added for tinnitus assessment.

Right now, the Audiology representation on the AMA coding committee is a representative of ASHA. There is also input from ENT and Neurology. It is very difficult to get agreement from all these different groups, therefore, changes occur very slowly. Technology and medical/clinical evidence often precedes coding by several years. Right now the coding for caloric irrigation (92543), rotational testing (92546), posturography (92548) and vertical data recording (92547) needs to be updated.

When the definitions of a particular code are vague or outdated, there is much confusion. When a policy is not clear, it opens the door for varied interpretation and potential abuse. When a code is frequently used incorrectly or is abused, Medicare’s response is often to simply deny payment or to so drastically reduce reimbursement that the overuse will be inconsequential financially. In 2004 the code for vertical data recordings (92547) was being abused. An irresponsible equipment distributor was selling equipment by pointing out how much money could be made by taking advantage of a billing “loophole” surrounding this particular code. Opportunistic practitioners (some, but not most, were Audiologists) started billing excessive amounts for 92547. Medicare’s response was to reduce reimbursement for 92547 from about $45 in 2004 to about $5 for 2005.

There are many nuances to coding and billing. Most private insurance companies follow the lead of Medicare, but you might find that some private insurance companies do not cover codes that are covered by Medicare. We find that many private companies do not reimburse for posturography, while Medicare does. This also differs from state to state. There are several different regional carriers from Medicare. In some states it might be Blue Cross/Blue Shield, while another state might be Aetna or Nationwide. Each regional carrier will develop their own policies and guidelines, so the rules in WV might be different than the rules in PA. Okay, now that I have you completely confused I should clarify all of this. Sorry! The fact is that coding is a blurry distant moving target. If you bill too conservatively, you hamper your bottom line. If you bill too aggressively, you open yourself up for recovery and penalties. Nobody said this was going to be easy.

You should remember the vestibular codes (numbers and definitions), and be able to discuss them coherently. Unless you end up in a retail dispensing practice, managing CPT codes and reimbursement is crucial to your income.