Health care reforms are bringing changes to health insurance plans and pushing providers to improve the continuity and coordination of care, in an effort to improve patient outcomes and provide cost-effective and efficient care. A significant impact of these measures in sleep medicine is the shift toward home sleep apnea testing (HSAT) for diagnosing obstructive sleep apnea (OSA) and increasing attention to developing practices for improving positive airway pressure (PAP) therapy delivery and compliance. The sleep center is moving from a fee-for-service reimbursement model to an outcomes-based model. The purpose is to reduce costs and optimize patient care.

Sleep testing is trending more and more toward HSAT, rather than in-laboratory overnight testing, and this is directly related to the payer policies. Sleep centers have seen different degrees of adoption of HSAT; however, the trend is shifting away from overnight in-laboratory testing because of changes in reimbursement. This trend is affecting the growth of sleep centers and altering the necessary skill level and knowledge base of technologists (1).

Historically, the majority of patients referred for overnight testing were being evaluated for suspected OSA. With the huge impact of HSAT as the primary diagnostic tool for diagnosing these patients, the dynamics of in-laboratory overnight testing needs to focus on evaluating complex patients with multiple comorbidities (2). These patients include those with hypoventilation, chronic respiratory failure, and premature infants with complex breathing problems.

To manage overnight testing for complex patients, sleep technologists require proper education and strong critical thinking skills. Technologists need to perform patient assessments and be familiar with looking at patient test results (e.g., pulmonary function tests, routine blood work, echocardiograms). It is critical that technologists have a good understanding of the underlying pathophysiology of particular disease processes. Complex patients require close monitoring of ventilatory patterns while they are sleeping. Technologists also require the knowledge to manage complex ventilatory devices like volume-assured pressure support and adaptive servo-ventilation.

The changes occurring are providing technologists an opportunity to utilize their skills in an ambulatory sleep center or office-based sleep program. This necessitates that sleep laboratories become comprehensive sleep centers, and that physicians educate and work with technologists to integrate their skills into the patient care process. Services that can benefit from technologist knowledge and skills and reduce physician workload may include a PAP follow-up program, a PAP walk-in clinic, an alternative therapy program, or an insomnia program. Expansion of sleep center services could also include neonatal and
pediatric inpatient testing, and a perioperative screening program. The technologist/clinician’s role includes utilizing clinical judgment by making clinical assessments, providing patient education, communicating test results to the patient, and communicating with nonsleep department medical staff.

Another function that can benefit from technologist knowledge and experience is management of the testing and treatment authorization processes. With the introduction of HSAT, the majority of basic OSA patients are being referred for a daytime educational instruction and sent home with a cardiorespiratory device for overnight testing. HSAT is much less expensive than in-laboratory testing and can accurately assess the patient suspected to have moderate-to-severe obstructive apnea (3). Patients requiring differential diagnoses, those with complex comorbidities, and pediatric patients will still require overnight polysomnography (PSG).

The insurance type (e.g., Preferred Provider Organization, Health Maintenance Organization, Medicare, Medicaid) will determine how an authorization is obtained. Multiple private insurers not only require preauthorization but regularly make use of utilization management companies to review preauthorization documents. Utilization management incorporates devices and methods for determining if the testing is medically necessary and if the patient can be tested using HSAT versus in-laboratory overnight testing. The utilization management companies’ purpose is to assist the insurer to form authorization processes. The downside of utilization management is clinical decision limitations to the physician. In many cases the need for an in-laboratory assessment requires additional effort by the provider to obtain preauthorization.

Some sleep facilities require the physician’s office to obtain the insurance authorization before sending the referral to the sleep center; however, sleep center personnel may have the responsibility for obtaining preauthorization. When a referral is received, it should specify the type of study ordered or if a sleep physician consult is necessary before testing. Some facilities consider the referral as the prescription; otherwise, a prescription stating the type of study needs to be provided. A history and physical that includes a sleep history, along with patient demographics and insurance billing information, will need to accompany the referral. The sleep history should include documentation of body mass index, height, weight, and neck size.

Depending on the insurance company and type of insurance plan it may take several days to a couple of weeks to obtain authorization. To obtain insurance authorization, the appropriate International Classification of Diseases (ICD)-10 diagnosis codes will need to be listed to identify the patient’s symptoms. An appropriate procedure code like the Current Procedural Terminology (CPT) is also required for authorization of the type of study to be conducted. It is important to know which procedure codes a particular insurer accepts. For example, for HSAT testing, some insurers accept a G-code procedure code, whereas others accept the corresponding CPT procedure code. There are also specific procedure codes for pediatric patients less than 6 years of age. It is the provider’s responsibility to contact the insurance company to identify which codes are accepted for testing. It is recommended to have a list of procedural codes available for reference. Be mindful to contact the insurance company if the study conducted fell under a different CPT code than what was authorized (e.g., code 95811—PSG with PAP was authorized but 95810—PSG was completed). Sleep center personnel are often also required to verify the patient’s insurance benefits and determine any deductible or copayment that may be required. This information should be available to review with the patient at the time of scheduling, so that he or she is informed of payment due before the sleep study date.

These functions often are most easily accomplished by a sleep technologist with a knowledge of sleep disorders and their symptoms as well as comorbidities that might influence the decision to approve in-laboratory testing as against HSAT.