A clarification to a local coverage determination has some sleep centers rushing to earn a tailored accreditation to continue to get reimbursed for polysomnography. Some call for additional communication channels between Medicare and its providers.
Many sleep centers, particularly those affiliated with hospitals, are scrambling to get their facilities accredited in light of reimbursement requirements put forth by several Medicare Administrative Contractors (MACs). These rules, outlined in local coverage determinations (LCDs), specify the credentials required for sleep center staff and mandate that any location performing sleep studies other than a patient’s home be accredited by the American Academy of Sleep Medicine (AASM), The Joint Commission (TJC), or the Accreditation Commission for Health Care (ACHC). Without this stamp of approval, facilities risk denial of coverage for their Medicare patients.
The rule caused confusion earlier this year when the LCD, L36839, issued by the MAC Wisconsin Physicians Services (WPS) went into effect. WPS and Centers for Medicare and Medicaid (CMS) maintains L36839 was a clarification of pre-existing policy, but the revision puzzled many sleep center administrators. Hospital representatives wondered if their pre-existing accreditation by The Joint Commission would satisfy this requirement (it doesn’t unless the hospital specifically requests The Joint Commission ambulatory care accreditation, which would then be tailored with their hospital accreditation.) Others were confused by what was required of providers compared with what was required of facilities. And many felt blindsided by the speed with which the policy was enacted. Accreditation can take as long as six months, and some in the business only became aware of the requirement just weeks before a revised version of the rule went into effect on February 16.
WPS could not be reached for comment, but a CMS spokesperson told Sleep Review in an email that WPS “went beyond the requirements for a clarification to an LCD and provided a 45 day comment period, held an open meeting, took the draft to their Carrier Advisory Committee, and provided a 45 day notice period before the policy went into effect.”
Indeed, WPS advertised open meetings in Wisconsin and Nebraska held on October 3 of last year and sought comments from the public between October 6 and November 21, 2016. It alerted providers to these opportunities through an e-newsletter. But according to the Missouri Hospital Association, that method of communication meant a lot of providers were missed.
“WPS considers the posting of new, revised or retired LCDs in its eNews communication as sufficient to meet its obligations to providers. However, the eNews feature only is available to those who have subscribed to this service,” Herb Kuhn, president of the Missouri Hospital Association (MHA), wrote in an open letter to WPS on March 13. “WPS continues to urge providers to sign up for the eNews service, however, these communications are sent through the eNews subscription, failing to reach any providers not subscribed.”
Kuhn told Sleep Review in a phone interview that MHA is advocating for better communication between the Medicare administrator and providers.
“We’re saying let’s operate on a regular order. You as a contractor have duties to fulfill; we as healthcare providers have duties to fulfill,” Kuhn says. “If all were operated on a regular order this wouldn’t be an issue…as a result it’s creating the cessation of sleep services for an awful lot of people in our state and maybe others.”
Similar policies from CGS Administrators, Palmetto, and First Coast Service Options Inc are in effect now; Noridian’s will go into effect in June.
Playing Catch Up
More accreditations means more business, and more work, for accrediting companies. At ACHC, it’s all hands on deck, says Tim Safley, ACHC director of sleep and other programs, in a phone interview. Before this year, ACHC was processing one or two accreditations a month, he says; now that number is closer to 40.
“We’ve been able to get them done,” he told Sleep Review. “The longest we’ve had to wait right now is 45 days. Now that’s right now but we’re still seeing new applications come in. So it could go as far out as, I’d say, 90 to 120 days.”
Neeraj Kaplish, MD, vice chair of the AASM Insurance Policy Review Committee, says that the organization has been able to handle the increased demand without delays. “The challenge for unaccredited sleep facilities in the applicable jurisdictions is that the policy changes were implemented with little advance notice,” he wrote to Sleep Review. “AASM accreditation is a rigorous, comprehensive process that includes a site visit, and applicants need time to complete the process. The AASM is continuing to communicate with Wisconsin Physician Service and CGS Administrators to appeal for special consideration for facilities that are in the process of earning accreditation. However, at this time, both contractors require current accreditation for payment of services.”
Safley says that well-prepared sleep centers can expect the process to go quickly and adds that poorly prepared sleep centers might not be eligible for accreditation at all.
“We have found sleep labs that want to get accredited, where we walked in and they didn’t have anybody that was a technician, a [registered polysomnographic technologist], a nurse, a registered respiratory therapist doing the study. Right there that’s fraudulent billing,” he says. “It’s not necessarily reporting them; it’s that we couldn’t accredit them.”
That observation is in line with the reasons CMS and WPS give for linking billing requirements to accreditation.
WPS explained its reasoning in response to a comment on the draft of L36839. “Often, non-accredited people are billing the federal government for services, and sleep studies are a major issue reported by [the Office of Inspector General, OIG] and law enforcement. The policy seeks to clarify which services qualify as sleep studies, what providers can order and perform them, and seeks to more clearly define home sleep testing.”
In 2013, the OIG reported that Medicare paid nearly $17 million for questionable polysomnography services.
Kuhn, of the MHA, sees patient care as the bottom line.
“If the Medicare program is about anything it’s about appropriate transitions because appropriate transitions makes sure you have appropriate access to care for Medicare beneficiaries,” he says. “And the times that they put in place here for people to get accreditation is just too short and very problematic and is creating breaks in services.”
The MHA is petitioning WPS to postpone the enforcement of the policy until more sleep centers can get caught up.
Rose Rimler is associate editor of Sleep Review.
States that are not included in WPS (Medicare part B)regarding Polysomnography from the LCD, are still being included in the requirement.
This is confusing and should be clarified.
There were only 5 states mentioned in the LCD that this effected, but is appears that WPS is applying it to all states without notice to the states, even though they were not included in the revision.
Sounds like Tom Price / Tru.p deregulation to me…wooohoooo
There is a huge business opportunity for sleep labs across the nation screening Medicare personnel for insomnia. There is no way that this population of “professionals” does not stay up all night dreaming of things that they can add to the already busy schedules of the real professionals taking care of the Medicare patients that they serve. This is has gotten and will continue to get more ridiculous. Enough already!
Hey Trumpland – are we winning yet?
Sleep Labs are for diagnosing mostly Sleep Apnea disorders. Insomnia? don’t think so
$17 mmmmmmmiiiiiillllliiiiiioooonnnn dollars. All at hospital sleep labs who billed both 95810 and 95811 for split nights. Oig report states 80% fraud / irregular billing found in hospital sleep labs.
Solution: oig/CMS goes on witch Hunt at all independent idtf sleep labs. You know, the other people who work hard to keep their doors open and do not possess a team of 25 lawyers to welcome 3 the oig inspectors. Oh look Ivan, no BMI in this one… Fraud.
Hello- I have a question and I am not sure who or where I can go to get an answer so I am just throwing this out here to start! If a physician wants a patient to have a sleep study in the clinic overnight a sleep center, the doctor provides a prescription as well as all pertinent clinical justification, the sleep center requests a prior authorization and it gets denied as “Not Medically Necessary” Even though the patient has all the co morbidities required. So the provider still has tha sleep center preform the study even though the prior Auth was denied, The study is complete and the patient is diagnosed with SEVERE obstructive sleep apnea so now a prior authorization is submitted for the Cpap equipment and the insurance company provides an authorization for the patient to obtain the equipment for treatment of the sleep apnea. My question is, How can the deny the outpatient procedure BUT will pay for the treatment that was deemed necessary with the justification from the sleep study the would not and will not pay for as they are still stating it is not medically necessary! Has anyone ever ran into this scenario?
Did you appeal the denial? If the patient met qualifications and the health plan is not following CMS guidelines you can get that overturned quite easily. Only if it’s a commercial and/or self-funded policy with special carve-outs and exclusions do CMS guidelines not apply.
Can a private party own a sleep lab? Can a dentist own a sleep lab?
If the sleep study service is covered by a contracted provider, is the accreditation in the name of the contracted service or the hospital based provider?