The American Academy of Sleep Medicine published several deeply researched diagnostics guidelines in 2017, but many insurance policies don’t match. This leads sleep medicine patients to only opt for the testing they can afford.
This year, the American Academy of Sleep Medicine (AASM) released new guidelines for diagnostic testing for patients with potential adult obstructive sleep apnea (OSA) and a position statement on home sleep apnea testing (HSAT). They reached the conclusion that in-lab polysomnography (PSG) at an accredited sleep center should be the standard diagnostic test, over HSAT, for suspected OSA.
But clinicians raise concern that the guidelines cannot consistently be followed in the real-world, citing third-policy payers that do not sync their policies to the AASM’s guidelines.
“The big problem you’ll see is the cost,” says Cheri Sellepack, sleep clinician and clinical coordinator at JFK Medical Center. “We have one insurance that provides a patient with an HST for free, but if they get an in-lab test done it’s $1,200.
“Unless the AASM is really working with the insurance companies about the needs of our patients, it probably won’t work out well. And it can be upsetting when you see the insurances more determining what should be ordered than the doctors.”
Ronald Chervin, MD, AASM immediate past president and board liaison for the Payer Policy Review Committee, says, “Our attitude at AASM has been that it is important for clinicians to recognize that HSAT is a valid diagnostic route for uncomplicated adult patients, but that it also has limitations. We also think insurers should recognize and understand the limitations that are delineated in those guidelines.”
Chervin warns that insurers should consider the costs of not properly diagnosing OSA, including patients who do not get accurate diagnosis and appropriate therapy done without it and so become more of a health liability in the long-run. Moreover, Chervin says he empathizes with the concerns of clinicians and patients who want quality testing done affordably. “The AASM definitely understands and shares the concerns that many of our members have about private payer policies and preauthorization decisions that don’t align with the AASM guidelines.”
When asked what the AASM can do to work with payers to address this issue, Chervin says it has always put in the effort to work with insurance companies. “The AASM notifies insurers when we publish a new clinical public practice guideline, and we definitely encourage that they adopt our recommendations into their policy. We also reach out to private payers whenever we see that their policies conflict with our guidelines, and we encourage them to change the policies so they will be able to provide high quality patient-centered care.”
He also explains that the AASM works with insurers to try and make sure their policies reflect the need to tailor testing for appropriate patients and points out unexpected consequences of conflicting policies (like missing a diagnosis).
“We think that we could work and develop good relationships with insurers to point out that there are circumstances where less costly approaches like HSAT are appropriate, but that in order to realize cost savings, they have to use them appropriately,” says Chervin. “If they are not using them appropriately, then they could well be providing less good health because of illnesses not addressed.”
Get advice on how to successfully make your case to an insurance company in our article “Preparing for Your Peer-to-Peer Review.”
Dillon Stickle is associate editor for Sleep Review.