Accredited Sleep Disorder Center HMS Diagnostics Inc reports that it has been the focus of an investigation by the US Department of Health and Human Services (HHS), Office of Inspector General (OIG), and the Federal Bureau of Investigation. Using what the company calls “a requirement little known in the sleep diagnostics industry,” the US Attorney's Office is suggesting HMS Diagnostics Inc may have improperly billed certain CPT codes for sleep tests that Medicare should not have reimbursed and is seeking a large settlement.

According to the company, the US Attorney's Office in conjunction with the HHS, the OIG, and the FBI, conducted a 10-month investigation of HMS Diagnostics Inc. They have concluded that HMS Diagnostics Inc may have improperly billed certain CPT codes for sleep tests that Medicare should not have reimbursed. They stated that they believe submission of those claims violated the False Claims Act, stating that the technicians did not have the required certifications for billing CPT 95810 and CPT 95811 (42.CFR 410.33 c), HMS Diagnostics Inc says. The claims that are being called a violation go back as far as January 1, 2002, and potentially involve substantial penalties. 

John Goodman, president of HMS Diagnostics Inc, feels strongly that very few people in the industry today are aware of this potentially very serious situation. “We believe that the majority of labs think the tech certification rules only just recently went into place, ie, as of October 1, 2007. But in fact, according to CMS, the regulation was actually published and effective since at least 2002.” However, from Goodman’s perspective, he says, “My research indicates that these regs were never spotlighted or otherwise highly advertised by the government, which seems unbelievably unfair to us and everyone else in the sleep industry.”

The company says that its practices are consistent with those of other accredited sleep centers that operated under the belief that certified technicians were required to directly attend each patient as of October 1, 2007 (not before this date). Upon receiving the result of the investigation, HMS Diagnostics Inc says it has found numerous articles about this requirement with dates as varied as February 26, 2007, October 1, 2007, and, January 1, 2008. The release claims that date confusion and conflict are apparent and widespread in the literature, legal opinions, and the regulations themselves.

There is also a requirement that states, "If a technician leaves the company, if a new technician is hired or when a technician's license expires and he obtains a renewal, the IDTF must provide this information to the carrier on an amended 855B with attachment II. Failure to do so may result in suspension of its Medicare provider number."

According to the release, the US Attorney's Office seems to be suggesting that any CPT 95810 or CPT 95811 study not actually performed by a credentialed technician cannot be billed. The fact that the credentialed technician is on site and supervising apparently is not a factor, HMS Diagnostics stated in the release.

HMS Diagnostics Inc seeks to inform other well-intended diagnostic facilities to pay extremely close attention to the potential pitfalls that have been created by government regulations and their interpretation by the government. “If what CMS is saying is true, then the amount of money that would be owed to Medicare by the industry is phenomenal,” says Goodman. “The liability potential on an industry such as ours with Medicare could be a very big number.”