Sleep reg shuts out providers

Sunday, August 31, 2008

For home medical equipment providers wondering if there might be a business opportunity in conducting home sleep tests for Medicare beneficiaries, the answer is a resounding no.

On July 18, the four DME MACs released revised local coverage determinations (LCDs) for CPAP, effectively squeezing out providers from the home sleep testing process. The LCDs state: “No aspect of an HST, including but not limited to delivery and/or pickup of the device, may be performed by a DME supplier. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.”

“Providers can’t have anything to do with it,” said Kelly Riley, director of The MED Group’s National Respiratory Network.

On March 13, CMS issued a national coverage determination stating that it would pay for home sleep tests, leading many in the HME industry to hope that providers might benefit. The decision by the DME MACs wasn’t a total surprise, but it was still disappointing, industry sources said.

“I kind of expected it,” said Eric Parkhill, vice president of Atlanta-based Home Medical Professionals. “I think Medicare is afraid of over utilization. There’s a huge population of undiagnosed patients and this is a good way of getting (treatment), but they had to balance it.”

Industry sources say a fear of fraud and abuse drove much of the revised policy, including other major changes. The policy, called the “Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea,” now restricts who can interpret test results to:

• A diplomat of the American Board of Sleep Medicine (ABSM);

• A diplomat in sleep medicine by a member board of the American Board of Medical Specialties (ABMS); or

• An active staff member of a sleep center or laboratory accredited by the American Academy of Sleep Medicine (AASM) or The Joint Commission.

“The opportunity for internal medicine or family practice physicians who have an interest in sleep medicine to look at the data is completely gone,” said Riley.

There are also changes to documentation requirements that may increase costs for providers, said Asela Cuervo, a healthcare attorney.

“Compliance (will now be) determined by a downloadable device,” she said. “Anybody who starts a CPAP after Sept. 1 is only covered for 12 weeks, unless they can show that the patient is compliant and benefiting from the therapy.”

If a provider can’t do that, or goes over the allowed time period, payments will stop, Cuervo said.

Overall, the policy is “good medicine,” industry sources said. A well-run CPAP business should have no trouble with the new requirements, they said.

“The doctor is going to have to work closely with the HME to prove compliance,” said Helen Kent, president of Carlsbad, Calif.-based Progressive Medical. “Those downloads are going to be the saving grace for the CPAP after 12 weeks.”