CMS revamps sleep policies

Friday, October 31, 2008

WASHINGTON--The new coverage criteria for CPAP devices issued Sept. 18 contains some provider-friendly elements, but it also has plenty of warts, say industry watchers.

The revised local coverage determination (LCD) stems from a controversy that arose when the original LCDs were published in July. Industry stakeholders at the time said that the LCDs strayed too far from an original national coverage determination issued in March in which Medicare said it would pay for home sleep tests.

The revised policies, for initial dates of service on or after Nov. 1, are an improvement, but they still ask providers to shoulder too much of the responsibility when it comes to educating physicians on the new rules.

For example, for initial coverage of a CPAP, the patient must have a face-to-face evaluation by the treating physician prior to the sleep test. That’s a problem because many physicians don’t do an in-person evaluation until after the test, said Todd Cressler, president and CEO of CressCare Medical in Harrisburg, Pa.

“It will be tough to get physicians to change their normal practice,” he said. “I think Medicare should make it the physician’s responsibility to follow this rule, not ours.”

Compliance requirements after the first three months of PAP therapy also require a face-to-face clinical re-evaluation performed by a physician.

Providers can tell beneficiaries upfront that if they don’t receive proof of the follow-up visit, they will be responsible for payment.

“If you’ve got patients with enough cognizance to go to a sleep lab, chances are they can assume more personal responsibility,” said Kelly Riley, executive director of the MED Group’s National Respiratory Network.

Whether they will is another question, says Cressler.

“We write off two Medicare patients a month for not getting back to us with compliance data,” he said. “We make it very easy for them, but there are always a couple who just don’t care.”

The revised policy also addresses re-qualifying patients who fail the initial 12-week trial period. In addition to a face-to-face re-evaluation with the physicians, the beneficiary must have a full sleep study in a lab.

Providers are still excluded from being involved in any aspect of a home sleep test, including the delivery and/or pick up of devices.

While that was expected, it’s disappointing, said Andrea Stark, a Medicare consultant with MiraVista.

“Suppliers are uniquely qualified in that they are constantly delivering equipment to the home environment,” she said. “I think it unnecessarily restricts access, which was intended to be liberalized by allowing home tests.”