Model for diagnosing sleep apnea evolves

Friday, October 19, 2012

ATLANTA – When it comes to getting new CPAP patients, the days of providers standing outside waiting for the sleep lab to throw them a bone are over, says Kelly Riley, director of The MED Group’s National Respiratory Network.

That's because sleep—from diagnosis to treatment to payment—is changing, said Riley during her Oct. 15 session, "Home Sleep Testing: Are You in or Out?"

"The prevalence and importance of sleep apnea is attracting a lot of attention," she said. "Of the top two healthcare concerns for 2012, one is sleep."

It should be. An estimated 10%, or 31 million Americans, suffer from obstructive sleep apnea, and only 30% of those have been diagnosed.

Home sleep testing (HST), in particular, has the power to influence those numbers for the better: It's more convenient for the patient and it's less costly, for both patient and payer, says Riley.

Payers know this. Over the past year, several major health plans have implemented prior authorizations for in-lab sleep studies as a way to encourage the use of HST, she says.

"Payers are definitely going that way," Riley said. "The bottom line is, it's less money."

These shifts in sleep therapy mean providers should be using a targeted approach to help physicians decide which of their patients should be tested for OSA, says Riley.

"Put a bit of a clinical spin on it," she said. "With the primary care physician, narrow his focus. He's not going to test all his patients."

Instead, providers can help the physician focus on patients who are obese, who have two or more prescriptions for high blood pressure, or who complain of tiredness or fatigue, Riley says.

"There's certainly opportunity for us in this because the goal is to identify and treat sleep apnea," she said. "If you don't get into this in some way, shape or form, somebody else will."


Theresa, one should check their payors to see if they will reimburse for HST by an HME. Most will follow medicare guidelines for this. The answer is no.


HST is an extremely viable solution for primary care and for patients.  There are many accredited IDTF that will handle HST, to include interpretation, while meeting CMS guidelines.  Management of uncomplicated OSA is treatment and developing a relationship with a good RT with experience is key to treatment success.  Unfortunately, PCPs don't believe they have the knowledge base to 'manage' sleep and the AASM has worked very hard to protect their territory.  The PCP is already treating their hypertension, CHF, diabetes - the PCP should be the one following the OSA.  An otherwise healthy individual without co-morbids such as CHF, uncontrolled diabetes, recent CVA, or other suspected sleep disorder (RLS, REM behavior disorder, etc) is a perfect candidate for HST followed by in-home auto-titration (if AHI returns at < 30 - > 30 should have an in-lab titration).