AASM staff, leadership and members, in coordination with AASM’s lobbying firm, McDermott+Consulting, have been working to resolve an urgent issue arising from an uptick in member audits involving claims for follow-up diagnostic sleep studies performed as required in local coverage determination policies. AASM members have reported that these audits have led to claims denials and protracted appeals, causing administrative and financial burdens.

Upon learning of this problem, AASM pursued a resolution with Noridian, the Medicare Administrative Contractor (MAC) for Region JF (10 mostly Northwestern and Southwestern states), and with officials at the Centers for Medicare & Medicaid Services (CMS) headquarters in Baltimore.

After several meetings and discussion with CMS representatives, the AASM has made substantial progress toward achieving significant relief for AASM members. Specifically, we anticipate that CMS and Noridian will take the following steps:

  1. Suspend Targeted Probe and Educate (TPE) sleep study audits in this jurisdiction
  2. Work to educate claims reviewers and auditors on permissible instances for follow-up diagnostic sleep studies

The AASM also is encouraging CMS and Noridian to provide more provider and supplier education to avoid this issue going forward. We believe that these actions will lead to fewer claims denials and easier resolution of pending appeals, relieving AASM members of administrative and financial burdens.

For questions or concerns regarding this matter, please contact the health policy team at coding@aasm.org.