Author: Kellye St Claire, MHA
With 18 years of experience in healthcare, including the last five focused on audiology, and a master’s degree in healthcare administration—a rare combination in an industry that blends healthcare and retail sales—I’ve observed significant areas of Medicare non-compliance. In some practices, sales are tied to staff commissions or contractual obligations to manufacturers, often linked to business loan repayments. These practices can expose audiologists to serious risks, including financial penalties, Medicare non-compliance, and even loss of licensure. Let’s answer common audiology related Medicare questions.
Hear me out…
Common Audiology and Medicare Questions
Every audiologist should be aware of their required Medicare obligations, especially if the average age of their patient demographic is 65 or older. The most common questions regarding Audiologists and Medicare are answered below from a high level.
Can audiologists opt out of Medicare?
One of the most common areas of confusion among new audiologists is the assumption that they can opt out of Medicare, much like physicians can. However, audiologists cannot opt out of Medicare. According to the June 2024 Medicare Benefit Policy Manual, if an audiologist treats a Medicare patient, they must submit claims for any covered services. Private contracts cannot be used to bypass these rules for services Medicare normally covers. Failing to comply with this mandate could result in penalties and reimbursement problems.
Can audiologists perform Medicare covered testing for free?
Providing free services that would otherwise be reimbursable by Medicare can create serious compliance issues. Under Medicare’s Anti-Kickback Statute, offering free services—such as hearing tests or adjustments—can be seen as an inducement to encourage patients to use your products or services. Even if done with good intentions, this could trigger legal scrutiny. To avoid complications, all services covered by Medicare must be billed according to the appropriate fee schedule. Even if the provider wishes to waive fees due to financial hardship, proper documentation is necessary.
Do audiologists have to submit claims to Medicare?
Yes. According to the Medicare Benefit Policy Manual, if services are provided without submitting claims, liability falls directly on the provider (the audiologist), not the entity owning the practice. Even in cases where ownership changes, providers remain responsible for submitting claims unless explicitly exempt. Failure to do so can lead to denied future claims, penalties, or exclusion from the Medicare program.
Risks of Medicare Non-Compliance
Not adhering to the Mandatory Claims Submission Rule exposes audiologists to various risks:
- Financial risks: Fines and potential repayment of funds
- Licensure risks: Suspension or revocation of their audiology license
- Legal risks: Exclusion from participation in the Medicare program
Accountability for Medicare Compliance
The CMS-855I Medicare Enrollment Application explicitly states that liability for compliance with Medicare laws rests with the provider. The Certification Statement in Section 15 signed by the audiologist reinforces that individual practitioners must follow Medicare’s regulations, and failure to do so can result in loss of billing privileges or severe penalties.
Accountability for Medicare Compliance remains with the provider!
Do medicare advantage plans have the same requirements?
The majority of Medicare Advantage plans follow Medicare guidelines. It is best practice to call the number on the back of the patient’s insurance card and confirm prior to rendering services. Patients enrolled in Medicare Advantage (MA) plans often expect their providers to follow Medicare rules, as these plans are required to offer at least the same benefits as traditional Medicare. However, MA plans may have additional requirements, such as network participation and prior authorizations. Audiologists must be familiar with these specific MA plan rules while adhering to Medicare’s core guidelines.
What if the audiologist is employed by an organization?
For audiologists serving Medicare patients and are employed by an entity, it is critical to consult with a healthcare or Medicare attorney. This ensures that the company policies comply with Medicare’s mandatory claim submission rules, as the individual provider remains responsible for compliance.
Here’s why it matters:
Medicare holds the individual provider accountable for:
- Claim submission
- Proper billing practices
- Documentation of services
Even if an employer has different policies, the audiologist must ensure that Medicare-covered services are billed correctly.
Consulting with a legal expert can help:
- Review the terms of employment agreements
- Ensure the employer policies don’t conflict with Medicare guidelines
- Protect the audiologist’s Medicare standing to avoid penalties or exclusion
By taking these steps, audiologists can safeguard their professional responsibilities while ensuring compliance with company policy.
Final Thought:
It’s always better to invest in compliance upfront, whether through legal consultation or proper Medicare training, than to be blindsided later by costly penalties, fines, or even loss of licensure. A small expense now to ensure everything is in order can save you from significant financial and professional consequences down the line.
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