Sleep apnea is a wide-spread affliction that affects an estimated 22 million Americans, of which roughly 80% of cases go undiagnosed according to the American Sleep Apnea Association. In order for sufferers to receive treatment, they must undergo a series of tests to determine specific diagnoses and effective treatment options, many of which occur in facilities such as sleep laboratories (commonly referred to as sleep centers).
Firstly, an overnight polysomnographic diagnostic sleep test (PSG) is performed to diagnose what sleep disorder, if any, a patient is experiencing. The results of the PSG test are then interpreted by a physician, who identifies any indications of obstructive sleep apnea. Should the test meet certain criteria, the patient is prescribed a subsequent CPAP Study. This test, though similar to the PSG, fits the patient with a CPAP machine and determines the appropriate settings that will allow for overnight relief of sleep apnea symptoms.
The testing can often be pricey, with patient cost ranging from $600 to $5,000 per night. Thankfully, both forms of testing and CPAP equipment are often eligible for Medicare and Medicaid coverage. CMS has a certain set of requirements for in-center sleep studies to qualify for reimbursement, including:
Unfortunately, these sleep labs sometimes utilize questionable billing practices in order to violate the False Claims Act and milk these government programs for undue reimbursement. The Office of the Inspector General found that between 2001 and 2009, sleep studies rose from $62 million to $235 million in Medicare reimbursement – with a steady rise of 8 to 9% each year since. By implementing certain unlawful techniques when certifying, coding, and billing for such tests, sleep labs can rob Medicare and Medicaid of vital funding. Some of these fraudulent practices include:
Through these tactics and a variety of others, the OIG estimated a loss of at least $17 million in unnecessary sleep testing between 2005 and 2011. With sleep apnea considered to be a $30 billion industry, these labs are ripe for Sleep Apnea scams and Medicare fraud – fraud which often goes undetected without the assistance of a whistleblower who seeks to do the right thing.
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