The type of benefit is not the issue. When a hearing aid is billed for using the appropriate diagnosis and CPT code, the insurance company will reimburse based on the contracted amount (if the provider is “in network”). It doesn’t matter how the benefit is classified. The only exception to this rule is things like FSA accounts, because they don’t require CPT codes. So when the provider is reimbursed and accepts payment for the hearing aid, they are not legally allowed to balance bill the patient for remaining balances. It is in the contracts we sign to be in network.
This is a factual example: A patient of mine came in and we had this very discussion. But she was a longtime friend of the ENT I was working for. So she didn’t want to go anywhere else for her aids, but was doubting what I was saying. I called BC/BS and verified her $3000 benefit. I did her evaluation, completed a recommendation, chose a pair of aids, and fit her. I billed BC/BS for her $3000 pair of aids and we waited for the check. 2 weeks later, a check came in from BC/BS for $60.00….$60.00!!! So instead of depositing the check, I showed it to her at her follow up appt. She was shocked. I sent the check back and she happily paid in full for her aids. Because I did not accept their payment and reversed the billing charge, I was not obligated to not balance bill her.
I know that it is disappointing that most insurance transactions are this way, but it isn’t because I don’t WANT to bill insurance for aids. It is because I would have to close my doors. The aids are billed as durable medical equipment and reimbursed as such. I am reimbursed more for a hearing test than I am for hearing aids. It can’t be billed as a “general reimbursement”.