Private Payers 2018-05-17T15:36:10+00:00

Private Payers

Guideline Scorecards

Guideline scorecards were created to evaluate how effective payer policies are at establishing appropriate coverage for diagnostic sleep testing services. The intent of the scorecards is to encourage insurers to adopt evidence-based policies that support patient safety and delivery of high-quality care.

The following scorecards for several major payers are based on the careful review of their policies by the AASM Payer Policy Review Committee, were approved by the AASM Board of Directors, and sent to each payer in advance for comment before posting online.

Diagnostic testing for obstructive sleep apnea

The AASM Payer Policy Review Committee based the Diagnostic Testing for Obstructive Sleep Apnea scorecard on the AASM’s 2017 clinical practice guideline on diagnostic testing for OSA. The scorecard’s nine criteria correspond to the clinical practice recommendations contained in the guideline.

AIM Specialty Health

UnitedHealthcare

eviCore

AASM Communication with Private Payers

The AASM understands our members’ concerns regarding private payer policies not aligning with the AASM practice standards. In light of the paradigm shift from in-center polysomnography and titration to HSAT and APAP, the AASM has been reaching out to private payers to ensure that the board-certified sleep medicine physician (BCSMP) is involved in the testing and management of patients. The AASM firmly believes that patients managed by the BCSMP receive high-quality care.

The AASM is in touch with payers on a regular basis commenting on and requesting changes to policies so that these policies align with our recommended standards for patient-centered care. The following letters are some examples of how the AASM has worked with various payers to provide guidance on policy making.

Key Definitions

HSAT

A home sleep apnea test (HSAT) is an unattended diagnostic study which assesses obstructive sleep apnea without the determination of sleep stage. The term specifies the condition being assessed (i.e., sleep apnea) by current technology without implying that “sleep” quality, staging or time are determined. The AASM recognizes that not all such studies are performed at home; however, “home” is included in the term because that is where the vast majority of patients undergo these tests. HSATs have also been referred to as home sleep tests, out of center sleep tests, and portable monitors. HSAT technology has been found to be comparable to polysomnography in the diagnosis of OSA in patients with high pre-test probability and no co-morbid conditions. In 2011, the AASM published an evaluation of technology for HSAT and began offering HSAT accreditation. In 2017, the AASM published an updated clinical guideline paper on diagnostic testing (both in-lab and HSAT) for adult OSA.

Utilization Management

Recently, insurance companies have started implementing utilization management programs for sleep testing. Utilization management is a tool/technique used to determine if a procedure or test is medically necessary. Usually, this technique is used for high-cost procedures and is intended to reduce unnecessary testing or procedures. In the case of sleep medicine, utilization management is used to determine when in-center testing is necessary and when a patient can be tested using HSAT.

Insurers often contract with outside companies to administer their utilization management program. These companies advertise reduced testing and procedure costs that result from implementing their utilization management programs. The utilization management company will work with the insurer to establish an authorization process for testing. These processes vary from insurer to insurer. Depending on the insurance policy and the utilization management company, sleep utilization management can be labor intensive for the provider. It can also limit the physician’s ability to make clinical decisions for his/her patients.

Preauthorization

Recently, more and more private insurers have started requiring preauthorization prior to sleep testing. Preauthorization is the process of confirming with an insurer not only whether or not a test or treatment is a covered service but also whether or not it is considered medically necessary for a specific patient. As described above, insurance companies frequently use utilization management companies to review preauthorization documentation. For sleep, this documentation can include signs and symptoms of OSA as well as a list of co-morbid conditions which might result in the patient requiring in-center sleep testing.