Waiving the Rules

Improving outcomes based on coordinated care of patients with chronic diseases is one of the cornerstones of the Patient Protection and Affordable Care Act. Providers hope to achieve this goal through accountable care organizations (ACOs), which consist of doctors, hospitals, and other health care providers who join forces and agree to be held accountable for improving care and reducing health care spending. The more these organizations save, the more they have available to share—they also share in losses if the costs exceed the plan.

What about sleep medicine? More and more, sleep apnea and other sleep disorders are being recognized as chronic conditions. Could sleep medicine practices become eligible for payments for coordinated care as ACOs? Based on several models and CMS approval, yes, but only if the CMS is willing to waive some reimbursement barriers that would prevent the integration of sleep medicine delivery.

One model of coordinated care is a physician-supervised facility offering both home and in-lab testing, along with a variety of treatment options. All services would be billed from a single facility or physician’s office. This model contravenes the Stark Law, however, which prevents physicians from billing CMS for PAP equipment and supplies dispensed from the referring physician’s practice. This law was put in place to prohibit a physician’s referral of CMS PAP to an entity in which the physician has a financial interest.¹ This makes sense, as it limits the opportunity for physicians to overutilize sleep medicine tests and therapy to their own financial gain.

CMS could limit its waiver, however, to integrated sleep programs that achieve and maintain an acceptable accreditation credential as an integrated sleep disorders center. This could safeguard against abusive, excessive use of sleep services.

Another change would have to be allowing durable medical equipment (DME) suppliers to colocate inside the office of an independent diagnostic testing facility (IDTF) or Medicare-enrolled physician practice. Colocating the supplier inside the IDTF or practice is an important aspect of integrated sleep care. To encourage the development of integrated sleep centers, CMS might need to look at the colocation prohibition.

The affiliation rule, too, would need to be reexamined. Currently, suppliers are not allowed to dispense Medicare PAP to a patient whose obstructive sleep apnea was diagnosed through a sleep test performed by a person affiliated with the supplier. To be true to the integrated care concept, however, this would need to change.

Finally, the anti-kickback statute that makes it a felony for a person to “knowingly and willfully solicit or receive any remuneration (including any kickback, bribe or rebate directly or indirectly, overtly or covertly, in cash or in kind) in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under [Medicare] or a State health care program”² also could be a barrier to integrated care.

Contact between patients with sleep disorders and all health care professionals is central to an integrated sleep program, and guidance from CMS on compliance issues could solve this problem.

—Marian Benjamin

References

1. Brown DB. When the payor takes control. Sleep Review. 2012;13(1):16-9.
2. Manning WL. Summary of The Medicare and Medicaid Patient Protection Act of 1987 (42 USC 1320a-7b). Available at: www.netreach.net/~wmanning/fasumm.htm. Accessed May 15, 2012.