Even before CMS rendered its March verdict to expand coverage of CPAPS for patients diagnosed with obstructive sleep apnea via home sleep testing devices types II, III and IV, providers have been eyeing home sleep testing as a new market opportunity.
Unattended home sleep testing is seen as the key to open the door to a population of tens of millions of OSA sufferers. While estimates put that population between 20 million and 40 million, only roughly 6 million people have been tested for the condition. Home testing is considered cost-effective, convenient and arguably more effective than lab studies.
Monitor LCD developments. At present, only two local coverage determinations have been released, so many providers are still waiting for what will surely be several more LCDs related to testing that will clarify testing qualifications, HCPCS codes, reimbursement and medical necessity requirements. Likewise, several more LCDs are expected to define the treatment component of HST. Also, so far, CMS has limited coverage of CPAPs for OSA to 12 weeks to ensure they are having an impact on the patient.
Act now. Don’t adopt a wait-and-see attitude as the LCDs take shape. “The delay of the LCDs is a way to turn lemons into lemonade,” says Kelly J. Riley, CRT, RCP, the director of the Med Group’s National Respiratory Network. Most providers are not as prepared for HST as they might think they are.
Learn the science of sleep. Providers should partner and learn from the individuals who are already deeply rooted in sleep testing, such as PCPs, sleep specialist physicians, sleep labs and the technologists doing the scoring. “For example, how many providers do you know that call on either psychiatrists or gynecologists?” Riley asks. “That’s really off the beaten path, but did you know that statistically the post-menopausal woman has twice the rate of OSA as the pre-menopausal woman?” Likewise, patients treated for depression can be as much as five times more likely to have OSA. Providers can be more of a trusted partner and establish their credibility if they understand the science related to the medicine.
Understand which patients are not HST candidates. Some patients are better served in a lab where scoring is more precise and detailed. Certain patient populations, such as those with co-morbidities, should be sent to the lab. A provider that acknowledges this and refers the patient to the lab will bolster its reputation for trustworthiness and credibility — the fundamentals for building long-term partnerships. Moreover it will create a reciprocal referral relationship with the lab.
Reach out to the community. Helping educate the public not only bolsters credibility, but serves as grassroots market outreach. Providers should work with other facilities to conduct sleep screenings, or speak at weight reduction meetings about the relationship between OSA and decreased leptin levels, for example.
This will also build the market for when the floodgates finally open. Because the provider has provided that outreach and screening, when all the LCDs finally come in and HST starts rolling full steam, there will be many more patients aware of OSA and ready to step up for testing. Moreover, they will be eager to do it in their homes because it suits their comfort levels and doesn’t represent the inconvenience the lab.
Start collecting and using data. Providers should also put into place mechanisms to track their success rates for compliance so that they can quote them to referral resources and discuss how those rates compare to national averages. In fact, the answers might surprise a provider that perhaps hasn’t tracked that data before, and serve as advance warning that it needs to improve one or more aspects of its sleep business, such as initial education or follow-up. “If they haven’t been collecting that data to this point, then they need to,” Riley says. “If it’s low, they need to ask, ‘Why?’” Digging into the data will describe the components for compliance and show the provider how it can improve patient outcomes.
Prepare your business to adjust for greater volumes. Given the potential patient population, a provider must have enough resources to serve more patients in a timely manner.
Empower your staff. Don’t assume that just because you have an RT on staff that he or she is aware of the latest HST developments. Help RTs to stay up to speed and ensure they understand the science of sleep. Likewise, train the sales staff. “Often times it is the sales staff that is interacting with the sleep lab or the physician,” Riley says. “Give them the tools to keep up with what is evolving.” Also, ensure that software-savvy team members are involved in the process so that they can start pulling the data you will need to benchmark and review your performance.
Points to take away:
• There will be many more LCDs released before HST takes shape. Keep watching them.
• Use this time to truly understand the science of sleep as a way to prepare your business and build relationship.
• Learn who are the real HST candidates and refer the rest to labs. This will build credibility and referrals.
• Reach out to the community to educate potential patients.
• Collect data on your performance and use it to determine where you can improve it.
• Prepare your business for new growth and your team to help improve outcomes.
So far, two LCDs have been released:
To view the LCD from Empire, visit www.empiremedicare.com/nyorkpolicya/policy/l26428_final_lcd_ngs.htm.
To view the LCD from Highmark Medicare Services, visit www.highmarkmedicareservices.com/policy/mac-ab/j12-d44.html.