Let’s Talk About the LMRP in Region VI

“Ask the Expert” is a column designed to address your questions or comments about management and dental sleep medicine issues. Send your questions to psmith@medpubs.com.

On behalf of the readers of Sleep Review, you should be aware of a situation in Centers for Medicare and Medicaid Services (CMS) Region VI (Dallas office) where sleep providers who receive Medicare reimbursement are being limited to those providers accredited by the American Academy of Sleep Medicine (AASM).

CMS Region VI reimbursement policies are set by its Fiscal Intermediary for that region, Arkansas Blue Cross, which issued a Local Medical Review Policy (LMRP) (AC03-030) entitled “Outpatient Sleep Studies” (effective December 15, 2003), which requires, among other things, studies to be reimbursed only if conducted in AASM-accredited sleep centers.

This LMRP, affecting states in CMS region VI (Arkansas, New Mexico, Oklahoma, eastern Missouri, and Louisiana), is having significant negative impact on both Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-accredited freestanding sleep centers, as well as hospital-based sleep centers in these areas, numbering over 100.

JCAHO is aggressively advocating on behalf of its customers with the fiscal intermediary on this issue.

—Michael Kulczycki
Executive Director
Ambulatory Accreditation/Business Development, JCAHO

Michael J. Breus, PhD, DABSM, responds:
As many people in region VI know, the following information was issued by CMS in the November issue of Medicare’s Providers’ News.

Policy: AC-03-030 LMRP Title: Outpatient Sleep Studies Effective Date: 12/15/2003

Some of the areas of highlighted concern include the quotes, “Space, equipment, and staffing must be consistent with the AASM Standards of Accreditation. All sleep studies must be performed in a center/laboratory that meets the following criteria:

“Each center/laboratory must have a Diplomat of the American Board of Sleep Medicine (ABSM) on staff or an individual who is currently accepted by the ABSM to sit for the certification examination. This individual may fulfill all the responsibilities of the board-certified sleep specialist in the sleep disorders center.

“Each center/laboratory must be accredited by and comply with the standards set by the AASM.

“Studies may be performed in a freestanding center that is a direct extension of a physician’s office or in an independent diagnostic testing facility provided that either facility is accredited by the AASM.”

This LMRP was having a significant impact on both JCAHO-accredited freestanding sleep centers, as well as hospital-based sleep centers in these areas (100-plus), because these centers are not AASM-accredited and the LMRP requires AASM accreditation to qualify for payment.

On December 1, 2003, JCAHO filed a “Reconsideration Request” with Arkansas Medicare Services. And on December 5, 2003, Arkansas Medicare Services responded to this Reconsideration Request, which read as follows:

“Outpatient Sleep Studies, AC-03-030 (Part A and B): The Description and Documentation Requirements sections of the policy that was published in our November 2003 Providers’ News contained certification/accreditation requirements that were effective with the implementation date of December 15, 2003; however, the carrier received comments during the notice period regarding the time frame required for certification. Therefore, we are postponing implementation of the certification/accreditation requirements until we can establish an appropriate time frame.”

Official and final response is still being awaited. Within 90 days of receipt of the letter, Arkansas Medicare Services must make a final reconsideration decision. We have heard nothing as of yet. SCMI can keep you informed of all the latest developments in regard to this and all other issues affecting sleep laboratories/centers by registering for our sleep alert service at www.sleepcmi.com. Medicare in this region is operated by Blue Cross/Blue Shield.

So what does this mean? It is impossible to say. On one hand, it is good that carriers in that region are interested in the high standards of care afforded by AASM-accredited centers, but on the other, it is not allowing those that may not be eligible for AASM accreditation (since we need more board-certified sleep doctors in all states) the ability to perform Medicare sleep studies and that may have just as high a standard of care (JCAHO-accredited centers). Is the carrier just looking for a way to deny sleep services? It may be possible, but more likely they are interested in the highest quality of care (wink, wink). What does that mean for the future of sleep medicine? Again, it is hard to tell but you can bet that this will continue to be an ongoing battle.

Keep sending those questions to Sleep Review!

Michael J. Breus, PhD, is Diplomate of the ABSM, and founder and senior partner, The Sleep Center Management Institute (SCMI), Atlanta; mbreus@sleepcmi.com.