VNG Questionnaire

In order to better evaluate your symptoms of imbalance or dizziness you are scheduled to have a series of special tests. First, if you haven't already done so, you will undergo a traditional hearing evaluation, even if hearing loss is not your primary complaint. Dizziness often stems from the inner ear and these evaluations can rule out some common problems that cause dizziness.

Next, you will have an assessment called Videonystagmography. In this test, we use video goggles with a camera in them to accurately document eye movement. With this technology, we can capture video and measure your eye movements. Your eye movements are directly related to what your inner ear (semicircular canals) is doing. They are the window into the function of the balance system.

• During the test, you will be asked to follow a light with your eyes while the movements of your eyes are being monitored. (There are 6 different tasks in this part of the test. Three of these are covered by insurance and three are not. See notice of insurance exclusions at the end of these forms).
• Then you will be moved in different simple body positions to determine if your balance system is responding normally.
• Finally, the audiologist will present cool and warm air to your ear canals. This will give you a sensation of spinning for a short time while your eye movements are being recorded.

The following preparations MUST be made prior to the test: Do NOT wear eye make-up. No eye shadow. No Mascara. No false lashes.Do NOT wear earrings.Do NOT take medicines that make you sleepy, that help you sleep at night, or that control your dizziness (especially Dramamine, Bonine, or Meclizine) for 48 hours before the test.If you have any questions, please call us (239-332-0707). Consult the prescribing physician if you are concerned about discontinuing any medications.It may be advisable to eat lightly or to avoid eating prior to the test as you may feel nausea. You may want to arrange for someone to drive you home in the event you continue to feel dizzy after the test.

THIS TEST REQUIRES A FULL HOUR OF THE DOCTOR’S TIME. WE SET THIS TIME ASIDE FOR YOU. IF YOU ARE UNABLE TO MAKE YOUR SCHEDULED APPOINTMENT PLEASE CALL AT LEAST 24 HOURS PRIOR TO YOUR SCHEDULED TEST TIME (IF YOUR TEST IS ON MONDAY, PLEASE CALL ON FRIDAY) SO THAT WE MAY FILL YOUR SPOT WITH SOMEONE ALSO IN NEED OF THIS EVALUATION. CANCELLATIONS NOT MADE WITHIN 24 HOURS OF YOUR SCHEDULED TEST TIME, WILL INCUR A $50 CHARGE FOR THE UNUSED TIME.

Thank you for choosing us to care for your hearing and balance needs.  We are committed to your better hearing and resolution of your balance problems. Please understand that in order for us to maintain the highest level of care, payment must be received.  Payment is considered part of your service.  Due to the personnel resources and time commitment needed to provide the complex services offered, it is imperative that our patients be very faithful in keeping their scheduled appointments. We understand that unforeseen events occur that require last minute cancellations of appointments. However, our small center cannot be expected to bear the financial loss that occurs when this reserved appointment time goes unutilized.  If you make an appointment and are unable to attend, if we are not notified 24 hours prior to that appointment a $50 fee will be assessed.

Sometimes offices offer “Free Hearing Tests”.  In general, free hearing tests are  not really free; instead they are a lure to invite you into their offices so that they may sell you hearing aids.  In many cases the evaluation is not complete enough to fit you with hearing aids and is only finished once you have committed to the purchase.  If the test is complete,  the cost of the test is wrapped up in the price of the devices you purchase.  At Southwest Florida Center for Hearing and Balance we believe that the diagnostic tests we provide are of value in and of themselves whether you decide to follow our rehabilitation recommendations or not.  We believe that the doctoral degree our clinicians hold affords our patients accurate, reliable diagnostic data  followed by insightful interpretation and honest rehabilitation recommendations.  A charge will be assessed for any diagnostic procedure or service we perform.

All patients must complete our information sheet and provide us with updated insurance information if applicable.  We will accept assignment of many insurance benefits.  However, we do require that any copays or deductibles be paid at the time of service.  The balance is your responsibility whether your insurance company pays or not.  Your insurance policy is a contract between you and your insurance company.  We are not a party to that contract. We accept cash, checks, VISA, MasterCard, Discover and American Express.   With an increase in insurance plans as well policy and copay variations it is sometimes impossible for us to collect all the amount due at the time of service.  As a result if we are filing your insurance, we will require a credit card to be on file, stored securely through a third party.  Once your insurance has processed the claim and there is a balance due, we will send you an invoice via email.  If this invoice is not paid within 5 days, we will automatically charge the balance due to your credit card on file.  This in now way hinders your ability to appeal your insurance company’s decision.  If they determine the amount due is incorrect we will promptly refund this amount to your account once we receive the monies from the insurance company.

MEDICARE (and most insurance companies) will pay for an initial hearing evaluation, a cochlear implant evaluation, mapping or testing, Auditory Brainstem Response (ABR) and ECoG (Electrocochleography) once per year and when medically necessary without a physician referral.  Balance testing including  Videonystagmography (VNG) (excluding saccadic testing and headshake testing), Vestibular Evoked Myogenic Potentials (VEMP) must be medically necessary AND referred by a physician. If your visit meets these criteria, we can expect payment will be made through your insurance company. We will do our best to keep you informed if we expect your visit may not be covered.

Medicare and many insurance companies do not cover a routine hearing exam annually, though your audiologist may recommend you have an evaluation to determine the current status of your hearing and to verify the current settings on your hearing aids are appropriate. In addition, if you are purchasing a hearing aid and an evaluation has not been completed within 6 months, Florida Law requires a new hearing exam to be completed within 6 months of being fitted with new hearing aids.   Therefore, if your exam is an annual exam, prescheduled after your hearing aids have been fit, or for the purpose of a new hearing aid fitting, you will be expected to pay at the time of service.  The cost for a hearing exam is $128.75.  Many Medicare Advantage programs will cover an annual hearing evaluation.  If this is the case we will bill your insurance and expect payment from them.

Medicare and many insurances also do not cover wax removal by an audiologist nor do they cover treatment for BPPV when performed by an audiologisteven though these things are well within the scope of an audiologist’s practice and/or are necessary to help your doctor make a diagnosis.  As a result if you  proceed with either of these procedures you will incur an out of pocket expenses: $89 for wax removal and $118.45 for BPPV treatment.  Your doctor will advise you if this is recommended and obtain your consent before doing any treatment.

Not all cochlear implant services are covered by insurances; specifically, troubleshooting and counseling, and instruction on how to use the device or its wireless components.  Non reimbursed cochlear implant services will be charged $66.95 for each 15 minute segment of service.

Not all tests in a VNG battery are covered by insurance though they are important for helping your doctor to diagnose and treat your problem.  Tests included in the VNG that are not reimbursed by insurance include fixed saccades with recording, random saccades with recording and high frequency headshake with recording.  The total for these tests is $62.88 and are REQUIRED to be completed with our VNG test battery.

Thank you for understanding our Financial Position and Policy.  Please let us know if you have questions or concerns. 

 

 

 

I have read and understand the above financial policy.

There are services for which Medicare or your insurance will not pay.

• Medicare or your insurance does not pay for all of your health care costs.  Medicare or your insurance only pays for covered benefits.  Some items and services are not are not covered by Medicare or insurance and Medicare or your insurance will not pay for them.
• When you receive an item or service that is NOT a Medicare or insurance benefit, you are responsible to pay for it personally.

Medicare or commercial insurance will not pay for:

 Balance tests:  Fixed Saccades, Random Saccades, High Frequency Headshake Test

Because of the following Medicare/Insurane exclusion:

No CPT (current procedureal terminology) codes exist for these procedures though they are ALWAYS a NECESSARY part of the standard VNG battery.  With no coding available, insurance will not pay for these tests.  Regardless of insurance coverage we REQUIRE these tests as part of our VNG battery of tests ordered by your physician.

The purpose of this notice is to help you make an informed choice about whether or not to receive these items or services (and therefore the test battery as a whole)  knowing that you will have to pay for them yourself.  Before you make a decision, you should read this entire notice carefully.

1. Ask us to explain, if you don't understand why Medicare or your insurance won't pay. (The explanation is above in red).
2. Ask us how much these items or services will cost you (Estimated Cost: Fixed Saccades $24.96; Random Saccades $24.96; High Frequency Headshake Test with recording $12.96.  Total: $62.88.)

 

SUMMARY OF HOW WE WILL USE YOUR INFORMATION

We will potentially use your information in 4 different ways:

1.  We are obligated to share your condition and findings with the physician who referred you.  If no physician referred you we will only share it with a physician if you make this request.

2.  We will share the tests we did, our office notes and/or your diagnosis with your insurance company so that they will pay your claim.

3.  We will discuss your case with any person to whom you have given your permission to share it.

4.  We will invite you to share your experience at our office.  You may receive an email requesting feedback.  

If you would like to read the full text of our privacy notice, please use the QR code below to access the document.