Even though labs have had 3 years to adjust since HST came barreling onto our radar, many still have not fully reconfigured to adopt portable monitoring to their advantage. There is still time to jump aboard the HST train before being left behind in the dust. A hospital sleep services director explains how sleep centers can succeed with HST while also maintaining a robust in-lab program.

During the 1990s and into the new millennium, healthcare witnessed unprecedented growth of sleep disorders centers and laboratories both in and outside hospitals. The ubiquity of managed care dollars, patients, and upward spiraling revenues for associated services provided a broad foundation for facilities, physicians, and home care companies on which they could depend. Diagnostic nights of testing were often immediately followed by a second night of CPAP. Wait times for testing often exceeded 4 weeks, so scheduling back-to-back testing was fairly common and provided a way to expedite the care of a patient who badly needed treatment. CPAP setups were often done the morning after a titration study, which could provide sleep specialists with 2 or more weeks of compliance data prior to the next office visit.

Over the summer and fall of 2012, home sleep testing (HST)/portable monitoring (PM) testing requirements arrived like a runaway freight train. Perched at the controls were some of our best managed care payors. For many labs and centers, the advent of HST was a rude awakening and a change to how business had been done for more than two decades. And though PM technology had existed for some time, too many of us were unprepared for the way HST and PM forever changed the business of sleep medicine. In-lab testing for obstructive sleep apnea (OSA) had come to a crossroads. In one direction, the road to in-lab testing was cluttered with obstacles to how we historically practiced and what we held as our standard of care; in the other, there appeared HST and a new path to diagnosing OSA.

Just as many labs weren’t ready for this bold shift in practice, some payors were clearly unprepared for the administration and application of their own changes. Anecdotal (but consistent) reports from all over the country told of insurance staffs who demonstrated little to no fluency in polysomnographic terminology and who rambled haplessly through checklists, requiring the sleep labs’ preauthorization staffs to actually interrupt to give clinical information that contained bona fide comorbidities for in-lab approvals. Time required for procuring preauths ranged from immediate to more than 2 weeks, and in some cases clearly delayed care for patients. Though preauths come somewhat faster now (versus in 2012), examples still exist of payors whose staffs have to be forced to follow their own rules by way of appeal or peer review.

Since 2012, those labs that persevered and managed to make the conversion and necessary changes to remain in business have learned much about themselves and their programs. The world of sleep medicine has always made great strides to collaborate closely with related disciplines and reach out to others. At our core, however, most of us don’t like change when it is so sweeping and consuming. Ever tried to change the workflow within a lab where the changes affect the physicians, the lead tech, or the entire staff? Not a warm and fuzzy response, is it? Yet the cold truth is we are creatures of habit in an ever-changing world of healthcare. And change we must.

The Cascade of Change

In the early 1900s, legend has it that Henry Ford said, “If I had asked people what they wanted, they would have said faster horses.” During the 1990s when Steve Jobs was finishing and fielding technology that would revolutionize how we take pictures, Eastman-Kodak continued to make film and pour resources into its 20th-century “horse,” and, in 2012, filed for bankruptcy. Despite relentless advertising, promotion, and widespread use of new technology, Kodak declined to engage in the new world that sprang up around it and paid the price.

So how do we rebrand and relaunch what has been the traditional business model of the sleep lab or sleep center? What does our future look like? Epidemiology and the widely agreed upon population of undiagnosed apnea patients would lead us to believe that sleep centers and labs have a bright and healthy future. To ensure that future, however, we must all reexamine and in some cases redefine our business identities. Many current business practices and workflows are based on reimbursements and testing rules of the past (pre-HST). For many labs and centers, we’re still configured and staffed the same way, yet we collect less and less every year. In evaluating our business and service models, much of what seems so daunting and paradoxical is how to preserve high value to our patients and referrals, while earning less and less for what we provide.

To begin shaping and taking charge of our futures, we must all answer some pretty hard questions about how we do things and why:

  • What should my services include?
  • How little margin am I willing to accept?
  • What should be the duties of the day staff? What more can the night staff take on?
  • What are the skill sets and competencies my staff must have to take good care of the sicker patients who are now coming to our in-lab? Patients whose comorbidities will be heart failure, brittle COPD, diabetes, neuromuscular disease, metabolic syndrome, and more.
  • What will my business look like if I don’t take the sickest patients who easily qualify for in-lab studies?
  • Do I provide or outsource HST/PM?
  • Should we all not revisit the 2:1 patient to technologist staffing ratio? I don’t recommend three patients with one tech working alone, but note that nurses in hospitals routinely care for six or seven sick patients. (The 2:1 model is getting much harder to defend within hospitals.) Staffing ratios of 5:2 and 7:3 have been successfully used in some programs today and in the past even accredited under those ratios. The American Academy of Sleep Medicine standards for accreditation recommend a patient to technologist ratio of “2:1 under usual circumstances for attended polysomnography at accredited sleep facilities.”
  • Do I do durable medical equipment (DME)? Do I continue providing DME?
  • What additional services can my staff and resources provide?
  • Who are my referrals and what other businesses or practices should I reach out to?

No matter what the answers may be to these and other questions about your business, two pivotal answers that will play a role in determining your way forward are: how you utilize HST in your program, and how to rebrand services and product(s) based on the influence and assimilation of HST into your program. Notable volume reductions to in-lab testing over the last 3 years show signs of stabilizing in some areas while continuing in others. So what makes the difference in labs that have rebounded versus those that have not…or have even closed? The difference is those that are now stable or growing again have found how best to integrate HST/PM into their programs, and they operate more efficiently with the realities of new technology and reduced income.

The Way Forward

Rebranding in any industry is done for various reasons, and as we saw with new Coke in 1985, results and reception of rebranding sometimes produce less-than-favorable results. Companies seek to rebrand in order to: differentiate themselves from competitors, eliminate negative images of failed ventures, regain lost market share, deal with emergent situations, and, at times, simply convey a change in vision or direction. For sleep centers and labs, rebranding should occur both internally and externally. The answers to those operational questions should drive one’s brand.

The operations and workflow of HST either augment or impede a program, and that is the struggle many labs are still having. Even though it has been 3 years since the rules went into effect, fundamental retooling of workflows is “in progress” in many labs. So what does a lab need to succeed with HST and to maintain an in-lab program? The number-one requirement is proper staff alignment and education. If the staff who perform intake and preauths are not stone-cold experts on the rules and indications of HST versus in-lab studies, then the program faces an uphill battle—one that could turn into a very long and costly game of trial and error.

Staff Knowledge and Intake

  • All clerical, technical, and medical staff must know all the rules from each managed care payor and how they apply to any patient’s history and physical exam.
  • Insurance preauth staffs must provide reasonable turnaround to orders for in-lab testing that are sent to “review.”
  • When calling for a preauth, it may be necessary to interject with comorbidity information if the person taking the information speeds down a very carefully scripted checklist. I have heard of insurance representatives using language on these verbal checklists that don’t necessarily match medical terminology of the allowed comorbidities.
  • After an order has been in “review” for longer than the payor’s stated time for review or when it appears care is being delayed to an obvious in-lab patient, labs must escalate their inquiries and concerns and ask to speak with a supervisor at the insurance company or insist on peer review.
  • For hospital labs that are compelled to utilize centralized scheduling and preauth processing, this all can be very difficult. I myself and dozens of colleagues in various parts of the country all report the same difficulties and shortcomings of centralized scheduling handling sleep orders.

Workflow Design

  • From reception of orders to distribution of results and home care setup, every step of intake, testing, and therapy should be diagrammed to see how the in-lab workflow fits over the requirements of HST and the preauth time necessary to keep appropriate studies in-lab. Spend some time trying to identify duplicative steps or processes.
  • Some degree of duplication and inefficiency can usually be found in the workflow from intake to DME setup, once processes are laid out on a time continuum and every step is evaluated for value. A common one is the use of too much paper material where EMR/EHR is being utilized for the medical record. Using both electronic and paper charts is a big red flag that speaks to the lack of efficiency of a program. It speaks to excessive supply costs and the maintenance of two systems. The usual remedy to the situation is facilitating change with those who aren’t on board, or who need resources such as training and equipment to support their EHR/EMR.
  • Another problem relative to EMR/EHR is the test schedule. Modules for electronic scheduling are meant to be the primary source for patients being scheduled, not handwritten paper calendars that are duplicative, serve as a crutch to technology, and ultimately lead to errors affecting services.
  • Analysis of workflows should lead to revamping of job descriptions that may call for some “broad banding” of duties in small businesses in order to maximize staff utilization and keep costs in check.
  • Success at keeping orders and patients in the lab for testing reflects the expertise of how orders are handled relative to the application of payors’ rules.

Piedmont Atlanta HST Workflow

This flow chart, which is what we developed for the hospital where I work, demonstrates four possible outcomes of HST and possible next steps for patient care:


Figure 1. Certain patients (and diagnoses) we know will be more appropriate for AutoPAP devices, while others will benefit more from in-lab split night or all night titration. This chart shows a care track for patients tested on portable devices and partially incorporates insurance rules by which a home test patient may return as an in-lab study.

A more in-depth explanation of Figure 1 is as follows:

  • Option one provides the physician an in-lab opportunity for testing when patients present with negative OSA results, but with possibly a high Epworth or other signs of idiopathic hypersomnolence.
  • The second example shows an opportunity for an in-lab test when a patient demonstrates signs of central sleep apnea, Cheyne-Stokes respiration, or periodic breathing.
  • In the third box, a 2-night HST demonstrating technical failure will qualify in most cases for in-lab testing.
  • Our final example is one preferred by some physicians to expedite treatment. If a patient demonstrates compliance difficulty, then this too may allow a patient to return as an in-lab order for most managed care payors. Follow-up calls by both DME and sleep centers reinforce the relevance and importance of each patient’s therapy and may help identify problems not readily apparent in download data sets.

Final Thoughts



Throughout the many challenges of the last 3 years, sleep centers and laboratories have been compelled to retool processes, forfeit revenues, and, in many ways, do more with less. As creatures of habit, our doctors, technologists, and support staffs have all ridden the wave of change brought about by HST and declining reimbursements. The good news is what doesn’t kill us makes us stronger, and many of us are stronger. The bad news is that changes are not over and may never be. The Affordable Care Act, declining reimbursements, licensure issues for technologists, compliance requirements, and an entire cottage industry of gadgets and technology directed at substituting for the gold standard of in-lab testing will continue to challenge what we do and how we do it. And despite advances in technology, payor regulations, and additional time required to process orders for whatever form of testing may be indicated, our duty and obligation is to advocate for patients the best and most appropriate diagnostics and therapy for their presentation.

Robert L. Lindsey, MS, RPSGT, is director, neurophysiology and sleep services at Piedmont Atlanta and Piedmont Mountainside Hospitals in Atlanta. He is a member of Sleep Review’s editorial advisory board.