Duplicate polysomnography services are rarely medically necessary in consecutive years, according to Medicare fraud investigators and sleep medicine professionals.

Sleep facilities with unusually high percentages of billing for multiple polysomnography services may be routinely performing and billing Medicare for services that aren’t medically necessary, according to a study by the U.S. Office of Inspector General (OIG).

The OIG study defined repeated polysomnography testing as two or more claims for a client/patient in each of three consecutive years.

ACHC Standards

ACHC Sleep Accreditation Standards require sleep facilities to establish policies and procedures that address repeated polysomnography services.

SLC5-5A: Written policies and procedures are established and implemented that outline proper oversight for sleep retests.

The sleep lab/center has policies and procedures for the acceptance of clients/patients that have previously received sleep testing. The policies and procedures must include the criteria for retesting in a facility or a home setting. A board-certified physician in sleep medicine performs and documents an assessment of need for the retest.

Tips for Compliance

Engage your board-certified sleep physician in a chart review of all clients/patients referred for repeat testing to determine medical necessity. These reviews will help ensure your facility is properly billing Medicare as well as providing clients/patients with the most cost-effective pathway.

Helpful Hints

In order to accept a client/patient for retesting, the client/patient must have an assessment of need completed by a board-certified physician.

Possible reasons for a retest include:

• Technical failures and/or equipment malfunctions.
• When the medical director/sleep specialists determine the study was insufficient.
• If required by a third party (insurance provider or legal entity).
• When evidence is obtained during a follow-up visit with the referring physician that indicates a need to evaluate for additional sleep disorders not evident during prior testing.

Here for You

ACHC is more than an accreditor. We are your partner. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 458.