Wake Up Call for Sleep

The government is taking a closer look at Medicare coverage and payments for sleep therapy devices, which may be the next big reimbursement issue.

The American Association for Homecare has added sleep issues to its list of legislative priorities for the coming year. That list already includes competitive bidding, maintenance and service payments after the 36-month cap for oxygen therapy, the first-month purchase option for power wheelchairs and respiratory medications such as Xopenex.

Recent studies have associated cardiovascular disease with obstructive sleep apnea. More than 12 million people are affected by the disorder, and many receive treatment each year with a CPAP machine, which CMS acknowledges is safe and effective. Yet, the agency continues to provide conflicting policies on payment and testing related to these machines.

For years, debates have raged within CMS and the DME Medicare Administrative Contractors over the coverage of home sleep testing and whether it can be used to diagnose or treat OSA. Recently, multiple local coverage determinations and proposed rules have been released on home sleep testing and coverage, but these home care policies are troubling.

AAHomecare is convening a workgroup of sleep policy experts to respond and is voicing concerns to stakeholders in the sleep community and to the DME MAC medical directors.

Two issues require attention. The first is the DME MAC local coverage determinations for positive airway pressure (PAP) devices for the treatment of OSA. All four DME MACs have released similar LCDs on this issue.

The “initial coverage” and the “continued coverage” criteria are the two main points of contention. The initial coverage requires a face-to-face clinical evaluation with some additional sleep test documentation. The continued coverage criteria include another clinical evaluation after three months of therapy.

There is a high rate of noncompliance with this treatment; however, requiring the beneficiary to return for an evaluation in the fourth month can be a burden for many patients. There is also an ongoing payment liability on the patient and HME provider tied to the face-to-face re-evaluation that requires compliance records showing clinical adherence of 30 consecutive days of using the machine for four or more hours per night.

The second issue entails CMS’ proposed rule on CPAP reimbursement, which may alter established CPAP reimbursements. CMS published a proposed rule in the July 7 Federal Register that states “a supplier cannot receive Medicare payment for a CPAP device if that supplier, or its affiliate, is directly or indirectly the provider of the sleep test that is used to diagnose a Medicare beneficiary with obstructive sleep apnea.”

The association will be requesting from CMS a definition of the term “affiliate.”

Policies and regulations being introduced by CMS lead us to believe the agency is restricting the involvement of home care providers. These policy changes have the potential for reducing quality of care and patient access to care.

Tim Hatt of Wright and Filippis notes that allowing HME companies to conduct sleep testing would greatly alleviate the backlog at polysomnography labs and lower costs. Patients can be tested much faster when HME providers are involved.

Also, raising the threshold for medical necessity further restricting home sleep testing and keeping the diagnostic component in the facility-based sleep labs will all add administrative costs for providers and patients and will place both at financial risk for potential non-coverage.

So where do we go from here? AAHomecare’s sleep workgroup will continue to meet and discuss the policies surrounding CPAP testing and payment policies in order to ensure that Medicare patients and providers are protected. If your company provides respiratory therapy services and you are interested in learning more, contact the association and stay tuned for updates as our sleep experts delve further into these regulatory issues.

Tyler J. Wilson is president and CEO of the American Association for Homecare, headquartered in Arlington, Va. He may be reached at [email protected]. For more information on critical home care issues, visit the association’s Web site at www.aahomecare.org.