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.