Managed Care and Sleep Medicine

Transcription

1 Managed Care and Sleep Medicine Denice Logan, DO, FACOI Regional Medical Director Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

2 Disclosure BCN Medical Director Associate Professor Michigan State University CHM 2

3 Objectives Be familiar with the indications per the medical policy for BCN members to have a HST. Be familiar with the date for the change in the policy Know an important prerequisite for an in facility PSG 3

4 Managed Care and Sleep Medicine American Academy of Sleep Medicine accredited sleep center in US has increased fourfold over the past 10 years. OSA still fails to be diagnosed or treated, suggesting inadequite resource numbers to meet the growing demands. CMS reimbursement has been targeted to reduce healthcare expenditures mandating more efficient approaches for diagnosing and managing chronic diseases such as OSA. Laboratory based PSG may be access limiting or delayed. HST may be able to address this access and delay. SLEEP, Vol. 35, No 6,2012

5 Sleep Test Optimization Programs: United Health Care No pre-authorization for HST-2012 Humana Facility based sleep studies Aetna no pre-authorization for HST Amerigroup NovaSom (pre-authorization) Priority - No preauthorization for a HST unless testing by a Medicare certified participating provider with a Type III test device (then pre authorization is required) Cigna HST preauthorization required yes Anthem BCBS Preauthorization yes BCN-HST preauthorization yes, PSG yes 5

6 Managed Care and Sleep Medicine Changes for sleep management July 1, 2013 Pre-authorization for BCN commercial, BCN Advantage HMO-POS and BCN Advantage HMO Adult members with symptoms of OSA without other co-morbidities that would interfere with the test results will require a HST, and if HST non diagnostic with a high probability of moderate to severe sleep apnea, will qualify for an in facility test Providers will submit requests for clinical review of sleep studies to BCN on e-referral 6

7 Sleep Studies - BCN Provider Affairs Overview June 2013 What Changed? Sleep Studies continue to require authorization. Three auth forms instead of two: Home Monitored Outpatient Home Unattended (new) Tests available to members has increased: Added unattended home study (95806/G3099) Unattended Home Study prior to outpatient study required based on clinical criteria Providers must be specifically contracted for sleep testing: New Fee Schedule Quality Standards Special Payment Exhibit Board-certified sleep medicine physicians can be on panel with or without Night Hawk to interpret home studies (home & monitored tests)

8 Managed Care and Sleep Medicine Indications for HST for OSA: Age 18 or > High Pretest probability of moderate to severe OSA AASM-high pretest probability in moderate to severe OSA (adjusted neck circumference > 43cm (17inches) and the presence of excessive daytime sleepiness Epworth sleepiness scale >10) Ajusted neck circumference + 3cm (If habitual snorer) + 4cm (HTN present) + 3cm (if apnea, gasping, choking most nights) The STOP-BANG criteria is included in the questionnaire, as questions which will score appropriately for consideration of the requested authorization. No comorbid diagnoses which would interfere with ventilation or the patient s ability to use the equipment or interfere with the interpretation of the test (Moderate to severe CHF, stroke with deficit affecting the airway or breathing, unstable Seizure Disorder, unstable Neuromuscular disorders, Narcolepsy, Parainsomnias, Unstable CAD, Central sleep apnea, obesity hypoventilation syndrome, Restless leg syndrome) Observed apnea during sleep 8

9 A combination of at least two of the following (A-E) A. Excessive daytime sleepiness, inappropriate daytime napping while driving conversing or eating, or interference with daily not explained by other conditions B. Habitual snoring, gasping/choking associated with awakenings C. Unexplained HTN D. Body mass index greater than 35kg/m2 E. Craniofacial or upper airway soft tissue abnormalities 9

10 References References: CMS Revises Sleep Medicine CPT Codes. In: AASM Special Update. Darien, II, American Academy of Sleep Medicine, 2011 Michigan Sleep Disorders Association Recommendation for Third Party Payer Sleep Medicine Policy September 25, 2012 Rosen, C Auckley D, Benca R, et al. A multi-site randomized trial of portable monitoring and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and management of obstructive sleep apnea. HomePAP study. Sleep 2010; 33 (Abstract supplement ) A173 SLEEP, Vol 35, No 6, 2012 Sleep Disorders, diagnosis and Medical Management Medical Policy- BCBSM/BCN 10

11 Questions? 11