In this rapidly changing world of medical insurance and American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine guidelines, understanding the difference between types of sleep labs is imperative. Independent Diagnostic Test Facilities (IDTF) and sleep centers provide many of the same services, but have concurrent distinct differences dictated by Safe Harbor, Stark, and anti-kickback laws. Knowing the differences can impact the dental sleep practice.
Sleep dentists are probably more familiar with independent diagnostic testing facilities. Most home sleep companies fall in to this category. IDTFs can provide sleep studies, be it a polysomnogram, split studies, titration studies, REM behavior disorders study (RBD), expanded EEG Sleep Recording (NPSG), multiple sleep latency test (MSLT), maintenance of wakefulness test (MWT), or a home sleep study. A sleep physician can read and interpret the sleep study and make treatment recommendations. However, no patients can be physically seen at the facility by the physician. This means a prescription for an oral appliance should not be provided. If a patient is seen by the interpreting physician, a violation of Medicare rules occurs and the IDTF can lose its Medicare number and will not be able to see any future Medicare patients. IDTFs are generally owned by business people who employ the interpreting physician. The IDTF bills insurance with the company’s national provider identification number (NPI). An IDTF can market their services directly to the public, physicians, and dentists with virtually no restrictions. IDTFs can test Medicare patients, but cannot provide any treatment for these patients. However, many knowingly circumvent this rule by having a friend or relative own the durable medical equipment (DME) company. This is a clear violation of Medicare rules. If an IDTF does not test Medicare patients, it can probably be assumed that at some time in the past a Medicare violation has occurred and their provider number has been revoked. “Sleep centers” operate under different rules.
Sleep centers are often owned by physicians, hospitals, and independent practice associations (IPAs). However, they can be owned by business people who hire a physician as a medical director. Oddly, insurance billing is under the physician’s NPI. Sleep centers can provide the same sleep studies as an IDTF. Historically, sleep centers generally favored PSG studies over home sleep studies. The supposition is that the physician will select the appropriate sleep study, PSG or HST, based on the patient’s health requirements. However, medical insurance companies are often insisting that home studies be performed unless the patient has co-morbidities. Even with the presence of co-morbidities, insurance companies are often overriding physician requests for a PSG and only paying for a home sleep study. Unlike an IDTF, sleep center physicians must see at least 40% of their patient’s pre and post study. Furthermore, at least 60% of the patients of the sleep center must be referred in by other physicians and dentists. Hence, at most only 40% of the patients tested can be self- generated. Sleep centers can test Medicare patients, but they can’t provide CPAP/BiPAP treatment for this group of patients. Regardless of which type of sleep center chosen for a sleep study, problems exist.
It is the position of the AASM and the AADSM that sleep apnea is medical condition that should be managed by a sleep physician, and ideally be tested by an accredited sleep facility. Few would argue with this position. But this does create a conundrum. Many areas of the country only have an independent testing facility. As previously stated, these facilities do not provide a sleep physician who can see the patient. In addition, the number of boarded sleep physicians who see patients is reportedly declining. A possible solution would be for the patient to be managed by a primary care physician. Unfortunately, the PCP has little to no education in sleep and most often has little desire or motivation to work with sleep patients. If the sleep dentist chooses to manage the patient, he or she is guilty of practicing medicine without a license, and furthermore, could possibly set themselves up for a malpractice lawsuit involving gross negligence…an event not covered by malpractice insurance. It would seem prudent to use a sleep center for testing, but sleep centers can be few and far between. Complicating matters, sleep centers often have long wait periods for sleep testing. So the million dollar question is what is the sleep dentist to do?
Often patients will learn about oral appliance therapy from other patients, the internet, or sources other than their physician. If the dentist lives in a state that permits dentists to order a sleep study, and the dentist wishes to send the patient for a sleep study, he or she needs to select an IDTF or a sleep center. At either facility the results should be interpreted by a boarded sleep physician. Before treatment should begin, guidelines suggest that the patient should be seen by a physician. If a sleep center has been used, the resident sleep physician there can see the patient. If an IDTF has been used, it would be logical for the patient’s primary care physician to see the patient. If an oral appliance is to be used, either physician can provide a prescription for oral appliance therapy. Medical insurance companies want to see the prescription for oral appliance therapy before payment is made. If the patient does not have a PCP, the sleep dentist should develop a relationship with a physician who is willing to see and manage sleep patients. Of course, insurance companies can complicate this by insisting the patient see only a physician in network. For this situation the patient will probably have to pay cash for services rendered, and this can be tricky as many patients believe all medical services should be paid by insurance. No one said life is easy. But there is more.
Not all patients will consent to a follow-up study, or will not consent to CPAP therapy if oral appliance treatment fails. If a sleep center is used, a follow-up pulse ox study of appliance efficacy, performed by the dental office, can be forwarded to the sleep center. The sleep physician then should decide on the ifs and when of a follow-up sleep study, and if further treatment is warranted. This places the burden on the sleep center. It is recommended that proper documentation be made. If an IDTF is used, then it may be wise to test efficacy with a pulse ox and forward the results to the PCP or your physician friend, who upon review of the pulse ox can prescribe a follow-up study and add additional therapy if needed. It should be noted that Medicare does not pay for any sleep studies ordered by a dentist. If the patient does not consent, the sleep dentist should insist that the patient should sign documentation that states he or she is refusing protocol.
There is no simple answer to the question of which should be used, an IDTF or a sleep center. The sleep dentist needs to understand the differences and act accordingly. Insurance coverage and mandates are intruding on the sleep practice and complicating matters. The sleep dentist also should understand the legal ramifications of his or her choices. Regardless, there is an obligation to treat sleepy patients and help them achieve better health. This means we have to find solutions.