Preauthorization and Home Sleep Testing

Heather Barskey
Director of Support Services
Advanced Sleep Management

The need to preauthorize sleep testing services has become a daily topic of conversation and requires tireless follow up in our programs. We are constantly looking to understand how regulatory and economic changes are affecting the way sleep disordered patients are diagnosed and treated.

Documentation of the necessity of testing is key in getting prior approvals. It is important that you look at specific medical policies that the billing facility is contracted with to understand the specific documentation requirement. These usually can be found on the insurance plan website. If the provider does not obtain prior authorization for services they perform, the claim will be denied in part or in whole for failure to obtain prior authorization and the member cannot be billed for the services. Retro authorizations are rarely allowed and may require additional time and efforts by staff. Many plans may deny in laboratory testing in favor of the home sleep test.
The referral coordinator carefully reviews physician documentation to make sure home sleep testing is appropriate, from the medical presentation as well as from a utilization standpoint. In comparison to laboratory testing, successful home sleep testing requires a much higher degree of cooperation from the patient. At a minimum, patient education in sensor application and device use is essential for high quality recordings. It is important for referring physicians to properly document all co-morbidities and patient limitations which would make a home sleep test contraindicated. Examples of appropriate documentation may include:

Moderate to severe pulmonary disease
Chronic Pulmonary Disease requiring supplemental oxygen
Neuromuscular disease
Congestive heart failure
Hypo-ventilation syndrome
Patient is under 18 years of age
Central sleep apnea
Periodic limb movements in sleep
Use of opiate narcotics
Patient limitations to understand or operate a home sleep testing device.

Home sleep testing minimizes contact time between the patient and sleep center professionals, reducing the opportunities to impart information and build a relationship with the patient. This puts an additional burden on the sleep technologist to orient and educate the patient during the home sleep testing process. We always have experienced registered sleep technologists do the education for home sleep testing. This reduces repeat testing and decreases the cost of the program. A more successful patient education program provides broader education. Patients are motivated to follow through with testing and treatment. One thing that we have found is that the patient should be made aware of the home sleep testing process and how it is used to foster proper diagnosis and treatment.

Home sleep testing has become an important part of our business and is helping us get more patients diagnosed and onto an appropriate treatment plan. The business of sleep is constantly changing but the prevalence of sleep disorders secures us with plenty of work to do!