Want to grow your sleep business in the new year via outsourcing aspects of diagnostic testing? This checklist will help you find a third-party HST service that meets your needs.

By Sree Roy

Partnering with a third-party home sleep testing (HST) service is about more than convenience. It’s a vital decision impacting both the efficiency of sleep medicine practices and the well-being of patients. Hitendra Patel, MD, FACP, FCCP, medical director of the high-volume, multi-location Wellstar Sleep Program, sheds light on this often-overlooked aspect of sleep business management.

His experience at Wellstar reveals a dilemma that large healthcare systems face: the logistical and financial challenges of managing inventories of HST devices. For smaller practices, managing a few devices might be feasible, but for larger systems, the logistics can quickly become a nightmare. Maintaining an extensive inventory, ensuring timely returns, and handling the turnaround are just some hurdles that can overwhelm even the most organized sleep centers.

Sleep testing is further complicated by third-party payor authorizations. “Say I have equipment on hand, and I want the patient to go home with it. But there’s an intermediate step: insurance and approval,” Patel says. Partnering with a third-party HST service has eased this quandary. “We do the insurance check ahead of time now, even before the device is shipped,” he says.

Patel’s experiences shed light on the decision-making process behind selecting an HST service. He and other stakeholders share their tips for vetting a vendor to determine whether it will be a good fit as a partner.

[Related: Home Sleep Testing (HST) Services Comparison Guide]

In this article:

Skip ahead to:

Compare costs | Set realistic reimbursement expectations | Understand any contractual commitments | Determine the HST type | View a sample study | Check the technology’s validation studies | Decide which elements will be outsourced | Be OK with their turnaround times | Trial the service | Gauge their technical quality control | Know their study success/failure rates | Confirm patient support hours | Check references

Business Aspects of Selecting an HST Service

Compare Costs. 

Though asking about the service price is likely at the top of any checklist, the cheapest option may not be the best fit. The price must consistently provide physicians with the needed sleep data and reports. 

You want to partner with an HST services company that ensures when sleep physicians “come to a diagnostic conclusion, you can be confident that it will withstand scrutiny,” says Troy Pridgeon, senior vice president of sales and marketing at software as a medical device maker SleepImage, which offers its software and ring- and fingertip-based HST devices as a service.

If the price is markedly different from competitors’, ask why. It could be more affordable because the device is lightweight, which keeps shipping costs down. Or perhaps it’s more expensive because a patient support hotline is available 24/7.

Also, compare pricing to the cost of keeping diagnostic HSTs in-house, including sleep tech time, shipping costs, patient training and support, retrieval of late devices, and other incidentals. “We have achieved scale, so our cost of operations per a specific patient can be much lower than a clinic’s cost of operation,” says Melih Alvo, senior director of commercial marketing at ZOLL Itamar, which offers a customizable WatchPAT Direct and end-to-end WatchPAT Solutions (also known as ZOLL IDTF) HST services.

Ask:

  • What is the price of the service, and what is included in that price?
  • What operational efficiencies does the service and/or software create that will reduce staff effort and expense?
  • Why is your price [higher/lower] than that of competing HST services?

Set Realistic Reimbursement Expectations. 

In some cases, the HST service provider will handle the billing, which means you won’t make money on the testing. Still, if outsourcing HST means patients arrive at their diagnosis quickly and can start their sleep apnea management plan significantly faster, that can be a worthwhile reason to partner with a third-party testing company.

But if the billing remains at your sleep practice, ask the HST service provider for a list of channels their device(s) records, as well as the billing codes with which other practices have found success. (Ultimately, confirm reimbursement with medical billing specialists and/or directly with the payors.)

Have realistic expectations for what the HST vendor charges for their services versus the amount your business will be reimbursed.

Ask:

  • What channels does the device record?
  • What billing codes are used by other sleep practices in my area for this device?

[Related: 4 Steps to Correct Coding for Home Sleep Apnea Testing]

Understand Any Contractual Commitments. 

Many HST services are commitment-free. Fees are incurred per sleep test, with no equipment to purchase or other capital expenditures. “WatchPAT Direct customers are in a consistent state of trial, meaning there are no minimum or maximum test commitments in a certain time when clinics are using our programs,” Alvo says of the HST programs’ no-commitment structure.

Other vendors, particularly companies with a focus on longitudinal monitoring, sell equipment with a time-based report subscription. 

Either way, an advantage of using a third-party HST service is scalability. “We have higher volumes at the end of the year,” Patel says. “On our own, we could not manage to have, for example, 200 devices go out at once.” By using an HST service, Wellstar accommodates the fluctuating demands without housing a huge inventory that isn’t needed for part of the year.

For businesses that need one-time help, ZOLL Itamar recently launched a WatchPAT Direct Beat the Backlog HST program that facilitates contacting up to 1,000 patients who are awaiting sleep studies in as quickly as two weeks. The program offers special rates to help sleep practices clear their desired backlogs. (There is no maximum limit for this program, but the time may vary for higher patient backlogs.)

In all cases, read the contract’s fine print to ensure it reflects exactly what was verbally discussed. 

Ask:

  • What are the minimum and maximum number of tests required?
  • How long is the commitment?

The HST Device 

Determine the HST Type. 

Several new categories of HST technologies have been launched in recent years. Decide the best fit for your patient population, whether that’s traditional type III cardiorespiratory devices or the growing category of type II at-home technologies, and how much ease of use matters (are wireless, wearable-style devices a fit?).

Some HST service companies have access to multiple devices. For example, VirtuOx’s HSATpro offers multiple testing devices from different manufacturers. “If one manufacturer has a disruption in their supply chain, a customer can quickly pivot to another device with little effort and disruption,” says Jon Fedele, founder and vice president of VirtuOx.

Also, consider what features are a must, such as the ability to do multi-night studies or to use the device with CPAP.

Ask:

  • What type(s) of devices do you offer?
  • What age ranges are appropriate for the device(s)?
  • Must the patient download a smartphone app, or is the HST self-contained?

View a Sample Study. 

Make sure the completed sleep studies will include all of the data that the sleep physician requires. Also, confirm the raw data is viewable and available for editing.

Ask:

  • Does the study assess total sleep time, and how? 
  • What templates are available to facilitate the creation of interpretation reports? 
  • What do any unique data metrics, such as atrial fibrillation detection (ZOLL Itamar) or a Sleep Quality Index (SleepImage), indicate?

Check the Technology’s Validation Studies. 

With so many different types of technologies available in sleep medicine, request a list of validation studies (many HST manufacturers have these listed on their websites), and read the data in full. How well does the device compare against in-lab polysomnography?

Ask:

  • How long has this technology been around?
  • What has the HST been compared against?

Workflow Considerations

Decide Which Elements Will Be Outsourced. 

And narrow the options to only the HST service vendors that offer the services you need. For example, do you only need help with HST shipments, or are physician interpretations needed too? 

“Over the past few years [CleveMed] added prior authorization, RPSGTs for manual scoring, staffing to help providers in manual processes like data entry, and just partnered with an outstanding sleep specialty group that can offer interpretations in situations where there is a specialist shortage,” says Sarah Weimer, senior director of sleep services and products at CleveMed, which offers a SleepView Direct HST service.

At ZOLL Itamar, HST services are also customizable. “We’re not just one-size-fits-all,” Alvo says. “Based on a customer’s needs, we can move parts around and together to create the best fit for our customers.”

Ask:

  • What specific HST services do you offer, and what is the total price for the services my facility desires?

Be OK With Their Turnaround Times. 

HST devices (including all disposable devices) that transmit the data to the cloud the morning after the sleep test will provide the data to the interpreting physician the quickest.

The disposable “WatchPAT ONE removes the shipping-back aspect, so you’ll get your results very quickly,” Patel says.

But as long as the turnaround time is a fit for your facility, the fastest option may not be necessary. 

Also, be sure to inquire how turnaround times may be delayed for extra high volumes of patients at certain times of the year or due to holiday closures.

Ask:

  • What is your average turnaround time?
  • How long does the patient have to take the test?
  • Does the service allow the patient to choose their exact delivery date?

Trial the Service.

Small practices that outsource 10 or fewer sleep tests a month can likely do fine without a trial, particularly since many HST services don’t require long-term commitments.

But for large health systems, running a pilot with staff members, spouses, and friends can be the best way to find out how seamless—or not—a specific vendor’s workflow will be. (Don’t do trials on real patients, as that can be construed as incentives for reimbursable services.)

HST service vendors tend to optimize their service elements over time. “Fewer footsteps and keystrokes are required, as the system provides many automated features, including patient SMS and email reminders to test, e-faxing completed reports to the ordering or referring providers, and more,” says VirtuOx’s Fedele.

Onera Health, which launched its PSG as a Service in the United States and parts of Europe in 2022, has already made modifications to improve workflows. Ruben de Francisco, PhD, founder and CEO, says, “For instance, which user needs to request the sleep study? At which point do we need to send a notification that the sleep study is ready? We’ve improved these elements to make it even more cost-efficient and to provide an even better user experience for the people involved, including the sleep techs. We understand that every little action equals a certain amount of time; that’s a cost for them.”

Ask:

  • Can I put several devices through the paces at my facility?
  • Are there any specific features, such as central sleep apnea detection, that you recommend be checked during the trial?
  • Can I check the test status at any time?
  • Can the software integrate with my facility’s electronic medical records software?

Gauge Their Technical Quality Control. 

Either during a trial or the first few weeks of use, decide if you are satisfied with the HST service company’s level of technical quality control.

For instance, though Bluetooth-synced HSTs provide faster turnaround times, they can also be prone to technical interference. Is that the case for these devices?

Also, does the transmitted study include everything that was promised? Or are entire study fields left blank?

“When all is said and done, no amount of low cost or convenience can compensate for a study with poor quality data,” says Richard Kaplan, PhD, president of General Sleep, which launched a Zmachine HomeDirect program in mid-2023.  

Ask:

  • Are there any known technical issues with the device or software?
  • Is there a good study guarantee?

It’s Your Reputation Too.

Know Their Study Success/Failure Rates. 

The success rate of an HST is impacted by both the device itself, such as its ease of use and how well the sensors stay in place, and the level of patient understanding of how to use and return the device.

At ZOLL Itamar, “we’re doing the patient training, education, and instruction on how to use the device and making sure the patient actually takes the sleep study,” Alvo says. “We’re not just shipping the device and letting them sit on it.”

Most HST service companies will provide step-by-step written and video instructions. Some will offer these in multiple languages.

Remember that it’s not just the reputation of the HST company that’s on the line; it’s your reputation as well.

“Every SleepView Direct patient kit goes with a survey which, we are happy to report, is filled out by the vast majority of patients. The results have been consistent and stellar year over year,” CleveMed’s Weimer says. “Q3 2023 results from over 8,000 respondents show over 95% overall patient satisfaction with our service.”

Ask:

  • What is your testing success rate?
  • Are the patient instructions clear and concise?
  • Are the instructions available in the languages needed for my patient population?

Confirm Patient Support Hours.

If the patient has a problem with taking their sleep study, they’ll need to contact the HST services vendor. So if a patient has a sensor dilemma at 3 am, will they be able to resolve it in time for a successful study?

Find out through which means—chat, email, phone—patients can contact the vendor and determine the hours when live support is available. 

Ask:

  • Describe your patient support, including the 24/7 support.
  • During what hours can a patient reach a live person?

Check References. 

There’s a good chance you’re only contacting HST services companies to which you were personally referred by another user. If so, that could be the only testimonial desired. But if you weren’t referred, ask for references before deciding.

“It’s very, very common to have people referred to us by current users, and at the same time, it’s not unusual to have somebody ask about other customers who are using the system currently,” says SleepImage’s Pridgeon.

Ask to be put in touch with facilities similar to yours in terms of patient populations and volume. “If they have a hesitance or shyness to reveal that, that’s a red flag,” Patel says.

Ask:

  • Can you put me in touch with two or three current users of your HST service?

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