Denied!

Before any patient has an appointment (initial office interview, follow-up interview, or sleep study), there should be a process in place for insurance verification and precertification. Before services are rendered, all insurance must be verified for a specific service. It is important to give sleep service codes (95811, 95810, 95805) and ask if there are provisions in this person’s plan for sleep services. Remember that precertification of a service does not mean a code (that service) is covered. Eligibility for a service means that the patient in question has a plan that covers the service your practice wants to provide. Many companies will issue a precertification number. This number along with the person’s first and last name at the company should be written in the patient’s permanent record. If insurance is not identified prior to the services being rendered, then your financial department should identify the patient as a “private pay” patient. Next, a payment plan needs to be put in place. Here, the patient will pay for half of the service before the sleep study or office visit, and then the remaining balance before results are given. In these situations, split nights may be the most economical for both the patient and practice. If insurance is verified and there is a co-payment or deductible, it is best to collect the co-payment or deductible before the sleep study.

In May 1999, the Medicare News listed several reasons for denial of sleep testing services. This list has also been adopted by many current third-party carriers. Thus, it is worthwhile at this point to review these reasons to get a continued feel for what may or may not be covered. If diagnostic testing is duplicative of previous sleep testing, previous results are still pertinent. Polysomnography, Multiple Sleep Latency Tests, and cardiorespiratory sleep studies are not covered under the following situations: diagnosis of chronic insomnia; preoperative evaluation of a patient undergoing laser-assisted uvulopalatopharyngoplasty without suspected obstructive sleep apnea; diagnosis of chronic lung disease (usually overnight oximetry is enough); cases of typical uncomplicated parasomnias; patients with epilepsy with no complaints of a sleep disorder; diagnosis of restless legs syndrome; diagnosis of insomnia related to depression; diagnosis of circadian rhythm disorder, shift-work sleep disorder, delayed sleep phase syndrome, advanced sleep phase syndrome, and non-24-hour sleep wake disorder.

Explanation of benefits (EOB) along with the corresponding claims should be monitored at the time the payment is posted to the patient’s account. EOBs should be evaluated for three possible problems:

1. Full Payment. This should not be seen as a success. If the insurance company pays 100% of the fee charged, it is likely that the fee is below the maximum that the company is willing to pay.

2. No Payment. This should be viewed as a coding error problem on the part of the physician or coverage limitation on the part of the insurance carriers. These cases should be discussed with the insurance carrier in the form of a coding discussion rather than doing a fee payment discussion. Many carriers will help you code the claim so that it can be paid if coverage is available under the policy. But they will not discuss why they did not pay the claim, nor will they tell you the usual, customary, or reasonable limits.

3. Reduced Payment. This can be caused by improper coding or by a fee schedule or usual and customary rate (UCR) limitation. Fee schedule or UCR limitations are usually shown on the explanation of benefits. Be sure not to intentionally unbundle a procedure that should be coded as one. Watch for the helpful “unbundling alerts” throughout the schedule.

Michael J. Breus, PhD, is Diplomate of the ABSM, and founder and senior partner, The Sleep Center Management Institute, Atlanta; www.sleepcentermanagement.com.