Third-Party-Payer Networks — Deciding the Right Mix of Payers for Your Practice

Jan 6, 2022 | Coding & Billing

Have you noticed there aren’t as many private payers in your patient mix? If not, you will soon enough: Baby boomers became the primary hearing-care demographic right as third-party payers and third-party administrators became commonplace in hearing care.

This perfect storm means staying informed and nimble is even more important than ever. So what can hearing care providers expect from these types of hearing aid plans?

“It’s going to be very individualized for a practice to decide whether they’re willing to accept that kind of payment,” says Debbie Abel, Au.D., Manager of Coding and Contracting at Audigy.


What Are Third-Party Payers?

You might have heard them referred to as third-party administrators, third-party hearing care benefit managers, third-party insurance contracts, or something similar. To simplify the matter, we’ll refer to them in this post as third-party payers, or TPPs.

Examples of TPPs include TruHearing, NationsHearing, and Amplifon. A TPP provides an insurance plan subscriber with hearing aid-related services on behalf of the insurance company. So why work with a TPP? You get access to patients who might not have been aware of your practice otherwise, because TPPs usually dictate which providers can be seen on their plan.


What Technology Options Do Third-Party Payers Allow?

It depends on the TPP, but you do need to use the technology indicated in the contract. Some TPPs allow tech from large manufacturers, like Starkey and Oticon, but restrict the choice of devices. Some have private labeling — maybe you have a choice with the TruHearing Select program, for example.


How Does Reimbursement Work?

Let’s consider an example of what the process looks like with a made-up — but typical — TPP:

  • You discuss technology options with your patient.
  • You submit your recommendation to the TPP.
  • The patient, the insurance company, or a combination of both covers a copay for the technology — let’s say $900.
  • The TPP sends the technology to you, and you fit the patient.
  • The TPP pays you based on the device level — in our example, you get $400 per ear.


Now let’s say after fulfilling the three required visits, you can bill for every single visit — but no more than $65/hour per visit. You can create a service package, but it can’t cost more than $250 per year. With that restriction, it may be better to have the patient pay $65 per appointment.

So, over the course of a year, if that patient pays out of pocket for 10 extra visits, you will have earned $800 for a binaural fitting fee plus $650 in additional visits — or $1,450. Is that going to be sufficient?

The variables involved from TPP to TPP are why you need to decide whether you can afford to include TPP patients in your patient mix.

Need help navigating the world of third-party payers?

How Do I Know Which Third-Party Payer Works Best for My Practice?

It all boils down to homework. First, look at your market through a demographic lens. For example:

  • Who is in your area?
  • Is there a major manufacturer?
  • Is there a large Medicare population?


With these and similar questions answered, contact the TPPs in your area. They should be able to give you an idea of how many patients might be referred to you on a regular basis. Then request a provider manual and fee schedule. This will give you valuable information such as the requirements of accepting patients and the lead time for patient arrival.

After the demographic and TPP pieces of the puzzle are in place, it should become clear whether any TPPs would be of benefit to your practice. For example, TruHearing contracts with a significant amount of Medicare Advantage plans, so if you’re living in an area where there are a lot of Medicare beneficiaries, that plan might hold a lot of potential.


Should I Contract With Third-Party Payers?

Depending on your situation, TPPs can be a welcome addition to your patient mix. You need to consider:

  • What your hourly rate should be
  • The time you will spend with each referral and how you will be reimbursed for that time
  • What the average patient receives with their warranty and how to charge for those services
  • The patient mix (insurance vs. private pay) you’ll need to make it work in your favor


You also need to consider your market. If a major employer in your area has contracted with any of those plans, that may be the only way you’ll capture those patients. Considerations include:

  • Your fitting fee is reduced, but you save money on marketing
  • The aid is ordered and paid for by the network (reduced cost of goods)
  • Payments often arrive in a few weeks — faster than many other fee schedules


Looking closely at the pros and cons will help you find the right balance between private-pay and TPP patients.


Future of Third-Party-Payer Networks

These TPPS are here to stay, and they’re expected to increase. Of course, there will always be private-pay patients, as not everyone will have access to a network like this. But it’s important to consider how the health care field is evolving, and how that ultimately affects the hearing care space. Maintain a good mix of your payers versus your private pay so that it’s balanced, and you’ll ensure your practice is thriving in the future.

Collect what you earn. Collect it more quickly. Improve patient relations.

Audigy Billing and Coding services can make it happen.

“We switched to Audigy Medical in fall 2019 and are happy we made the switch. Audigy helped us create attainable goals and break them up into a manageable checklist. We enjoy working with our practice management consultant and he helps keep us accountable for the goals that we set. We’ve also used the support of Deb Abel and she’s been able to answer all of our billing and coding questions. This is one of the main reasons we chose Audigy over other consulting groups. We are coming up on a year with being with Audigy and are happy with the service we’ve received.”

Chelsea Maag, Au.D., Pacific ENT Medical Group Inc.