Sleep Study Prior Authorization Services

The last decade has seen a huge spurt in not only the number of sleep medicine tests being ordered by physicians but also the number of registered Sleep Study labs in the US. Between 2005 and 2011 over 2,000 registered practices existed in the US but regulatory hurdles and the need to process dozens of Prior Authorizations (PA) have burdened Sleep Study practices significantly.

  • A 2015 AASM survey found that 80% of sleep physicians reported experiencing prior auth denials for sleep studies.
  • A 2017 study estimated that denied sleep apnea diagnoses due to prior auth delays cost the US healthcare system at least $440 million annually.

In this circumstance, sleep study practices have actively sought the help of dedicated Sleep Study Prior Authorization Services to cater to the increasing demand while also remaining compliant. In fact, sleep medicine has some of the strictest pre-approval requirements and establishing medical necessity for diagnostic sleep study tests is crucial to getting reimbursed on time.

Before we dive into how our prior authorization services for sleep study practices help them get over the prior approval hurdle, let us look into the specific challenges facing these laboratories.

Challenges in Prior Authorization for Sleep Study Medicine and Labs

Physicians generally order Sleep Study tests for one or more of the following conditions:

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  • Sleep apnea or other sleep-related breathing disorders where breathing stops and starts repeatedly during sleep.
  • Periodic limb movement disorder which is sometimes linked to restless legs syndrome.
  • Narcolepsy where patients experience overwhelming daytime drowsiness and can fall asleep suddenly.
  • REM sleep behavior disorder where patients may act out dreams during sleep.
  • Unusual behaviors during sleep like walking, moving around or rhythmic movements.
  • Unexplained long-lasting insomnia.

Since none of these conditions are acute or immediately life threatening, establishing medical necessity for a sleep study test becomes crucial to attain coverage from Medicare or private payers. Here are some figures worth noting.

  • 1-2 months: Average delay in sleep apnea diagnosis and treatment due to prior auth struggles.
  • 30%: Increase in healthcare costs for patients with undiagnosed and untreated sleep apnea.

There has been a growing reliance of home sleep apnea testing (HSAT) which is the sleep study equivalent of a step therapy. However, insurance companies often reimburse HSATs at lower rates than polysomnography (PSG) studies done at labs or dedicated facilities, reducing the income for sleep tests conducted at home. Despite the potential to have more patients, the decreased profit margin per patient is a drawback.

Moreover, HSATs, while useful, are less sensitive than PSG, especially in detecting central sleep apnea. The growing dependence on HSATs may strain the traditional sleep lab model, possibly causing job losses and lab closures for those unable to adapt.

Other challenges in prior authorization for sleep studies and related diagnostic tests are:

Administrative Burdens:

  1. Complex requirements: Each insurance company has its own PA criteria and procedures, often requiring extensive documentation and justification for the sleep study.
  2. Time-consuming process: Completing and submitting PA requests can be time-consuming for both physicians and staff. Obtaining precertification requires hour-long conversations with Payer representatives and dealing with IVR systems and proper communication with payers.
  3. Denial uncertainty: Payers may deny Prior Auth requests, even for cases with clear medical indications, causing delays and financial burdens.
  4. Staff shortages: There is an acknowledged lack of trained PA professionals with the right skill set to ensure quick approvals in the US. Most Sleep Study labs therefore depend on trained clinicians and in-house staff for documentation and obtaining prior authorization for tests, diverting them from essential duties.
  5. High costs of retaining specialists: Many Sleep Study practices find it financially burdensome to hire, train and retain a team of prior authorization specialists who would also manage documentation.

Clinical Misunderstandings:

  • Lack of awareness: Insurance company representatives may lack understanding of the importance of sleep studies in diagnosing and treating disorders, leading to denials for valid indications.
  • Focus on cost-effectiveness: Insurers may prioritize cost-cutting measures over long-term benefits, denying PA for potentially life-changing treatments like CPAP therapy for sleep apnea. Insurers pushing less expensive alternatives like home sleep apnea tests (HSATs) before approving full in-lab studies has a negative effect not only on swift diagnosis but profitability of sleep study practices.
  • Narrow criteria: PA criteria may not reflect the latest clinical guidelines or individual patient needs, resulting in unnecessary restrictions on access to sleep studies.

Many of these problems can only be addressed by engaging a dedicated team of PA professionals with extensive knowledge of Medicare and payer guidelines backed by automation and AI based document management systems. But such a solution brings with it a prohibitive upfront investment which turns away most sleep study practices.

When practices outsource Sleep Study Prior Authorization services, they get access to trained resources, cutting edge processes, extensive domain knowledge and massive cost savings. Let us find out about these benefits and the impact on sleep study practices.

Why Outsource to a Sleep Study Prior Authorization Service Provider

Discover the advantages of outsourcing your Sleep Study prior authorization which include:

Boosted Efficiency and Focus on Patient Care:

  • Leverage dedicated experts to handle complex prior auth tasks, freeing your staff to concentrate on patient care.
  • Benefit from streamlined processes, established workflows, and tools for faster approvals, minimizing delays.
  • Save time and resources by avoiding the administrative burden of dealing with insurance companies, paperwork, and appeals.

Enhanced Accuracy and Success Rates:

  • Tap into the expertise of outsourcing partners on insurance policies, ensuring up-to-date knowledge for successful prior auth submissions.
  • Mitigate risks with compliance and audit defense, reducing the chances of denials and audits.
  • Get negotiation and appeals support to maximize reimbursement rates.

Financial Advantages:

  • Experience increased revenue through reduced denials and faster approvals for reimbursed sleep studies.
  • Enjoy cost savings, as outsourcing may be more economical than hiring and training in-house staff.
  • Benefit from predictable billing with transparent service fees for budget certainty.

Additional Benefits:

  • Improve staff morale by reducing stress associated with prior auth struggles, allowing them to focus on patient care.
  • Access advanced technology and data analytics tools offered by outsourcing providers to optimize the prior auth process.
  • Adapt easily to fluctuating sleep study volumes with the scalability provided by outsourcing.

Important Considerations:

  1. Choose a reputable outsourcing provider with proven experience in sleep study prior auth and expertise in your region’s insurance landscape.
  2. Conduct a cost-benefit analysis to determine if the expected financial gains outweigh outsourcing fees.
  3. Ensure data security and privacy compliance by selecting a provider with robust measures aligned with HIPAA regulations.

Complete Prior Authorization Support for Sleep Study Practices

Sleep Study practices play a significant role in quality of life improvements for patients. As a leading Sleep Study prior authorization company, we are dedicated to deliver the same for your practice. Our support has allowed our partners across the US raise their profitability and reduce denials. By partnering with us, your practice gets:

  • Dedicated resources with US phone numbers, accessible during all US working days
  • Free Account Managers & Internal Auditors
  • Yearly maintenance of compliance certifications
  • Top-of-the-line infrastructure setup to protect against any malicious threat to PHI
  • Real-time audits and custom reporting
  • Real-time eligibility checks & fast authorization
  • 100% HIPAA-HITECH compliance
  • Rapid claim status analysis in denial management
  • Turnaround time less than 48 hours max.
  • Low service fees with no hidden cost

As the only Revenue Cycle Management company specializing in pre-certification for sleep study medicine, we deliver:

  • Guaranteed reduction of operational cost by up to 80%
  • Prompt service with a consistent accuracy rate of 99.9%
  • 150 to 200% Increase in rate of completed requests

Schedule a no strings attached consultation with our experts today and find out how we can wake your practice from financial slumber

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