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.
With over 34yrs in sleep medicine, we are STILL focusing far too much attention on the diagnosis of OSA. Yes, the gold standard is a full in-lab PSG (personally it should be a 1night split-night study for all pts).
Any lab with competent staff can properly diagnose & titrate CPAP all in 1 night, removing the need for a costly 2nd night. Only in rare &/or complicated cases is a 2nd night necessary. Insurance companies should have adopted this protocol yrs ago… would have saved millions in costs. I’m fine with HST’s as well… diagnosing is easy, it’s what you do afterwards that counts!
The focus however, is misguided! We should be laser-focused on the treatment side of OSA! We must understand that in most every case, you don’t cure sleep apnea… you MANAGE IT! It’s a long-term affair that requires the right people providing the right therapy on a very consistent basis (and I’m not talking about homecare companies!). Almost every sleep physician & sleep practice in the US should be providing sleep DME to all their pts for obvious reasons. We do it better, more efficiently & much more cost effectively. We’ve been doing it for over 8yrs with results that are unmatched. It’s the ideal, complete model for sleep medicine. Its a disgrace that the national avg. for CPAP compliance is maybe 50-60%. Our compliance has been over 95% for years! Most everyone today can wear CPAP successfully, given the technology we have now and having the right sleep professionals managing it! It makes no sense to send scores of pts out to HME’s that are poorly ran, disorganized & ill qualified to properly set up, instruct & manage YOUR pt for a lifetime! It hasn’t worked well so far, and never will.
THE SINGLE MOST IMPORTANT THING the AASM could accomplish is to have the Stark Laws revised by CMS to allow sleep practices the ability to provide DME for their own pts. NO ONE can take care of & manage that pt better than the sleep MD themselves. It is no more of a “conflict of interest” than a pulmonary practice doing there own chest xrays & PFT’s. It would save literally millions in healthcare costs, reduce the ridiculous complexity of managing compliance & working with terrible homecare providers, and most importantly would drastically improve the overall health & well-being of millions of pts, resulting in less healthcare costs on the many other comorbidities such as heart disease, diabetes, GERD, hypertension & stroke.
Come on AASM!! Surely by now you can make the compelling case for better sleep healthcare given the data & technology we have at our fingertips! I welcome your thoughts, esp those from the AASM.
K. Justice, RPSGT (Registry #87)
Another layer issue is safety sensitive transportation workers. Hst with chain of custody is an important step but additional cost for chain of custody are not normally coveted nor are most non specialty testing firms even able to provide hat with Cox.
Next you have dot medical examiner screening criteria completely ignoring 3rd party medical necessity requirements. This often results in claim denials.
These are problems we can fix.