In 2008, a jaw-dropping story from comedian Mike Birbiglia appeared on the public radio program This American Life. The episode was about the fear of sleep, and Birbiglia’s story detailed a little-understood condition that nearly killed him: sleepwalking.
Sleepwalking, or somnambulism, is a dangerous condition. Birbiglia had a dream that he was running from a missile headed for his second-story motel room. Unfortunately, without realizing it, he acted out the events of his dream. While still technically asleep, he jumped out of the second-story glass window, dropped to the lawn below, and continued running away from the missile he dreamed was chasing him.
He clearly lived to tell the tale, but that event understandably prompted him to seek immediate medical attention and, eventually, diagnosis.
Millions of Americans have sleep disorders as potentially life-altering as Birbiglia’s. Disorders like narcolepsy, sleep apnea, REM behavior disorder and insomnia have become more frequently diagnosed due largely to growing public awareness of their symptoms.
The rise in sleep disorder diagnoses may also be attributed, however, to the high reimbursements health care facilities can receive from Medicare or Medicaid for running extensive tests. This relatively new form of fraud does a disservice to government health care programs, taxpayers, and the millions of Americans who aren’t getting the quality of treatment they deserve.
An expensive diagnosis
Sleep apnea affects approximately 18 million Americans. It is characterized by intermittent interruptions in a patient’s breathing while he is asleep. People who are overweight, male or over 40 are particularly at risk for developing this disorder, which is often associated with loud and disruptive snoring.
Many sleep disorders require extensive testing to be diagnosed; sleep apnea testing and treatment involves significant equipment management and personnel supervision. After the initial physician consultation, the diagnostic process often involves a polysomnography test. A PSG is typically conducted in a lab specializing in sleep disorders. To perform the test, qualified medical specialists monitor the patient’s sleep patterns through sensors attached to the head, chest and limbs.
In many patients with sleep apnea, split-night tests are used. Instead of having the patient sleep normally throughout the entire night, the facility tests the patient’s activity while using a CPAP machine for the second half.
CPAP stands for “Continuous Positive Airway Pressure.” These machines are designed to prevent breathing interruptions in sleep apnea patients by regulating their breathing throughout the night. A CPAP machine consists of a mask, an air pump and the mechanism itself, which circulates air. It’s a clunky piece of equipment, and requires continuous use every night in order to sustain its effect. Without insurance, a CPAP machine could cost several hundred dollars.
Medicare and Medicaid cover most sleep tests and CPAP equipment, which means that registered sleep labs can receive high reimbursements for testing and treatment. PSG testing costs an estimated $1900 per night. Many medical facilities are able to sustain their practice by only specializing in sleep tests, without an additional focus on sleep disorder treatment. Home sleep tests are another, though less commonly used, testing option covered by government health care programs.
An opportunist’s dream
The Office of the Inspector General reported that Medicare spending for PSG testing rose 39% from $407 million in 2005 to $565 million in 2011. This agency also noted specific fraud cases where sleep specialists and clinics had requested and received improper reimbursements. Many of these cases involved whistleblowers that reported allegations of falsified records and the use of unqualified technicians to administer sleep tests.
In a 2013 case in Florida, diagnostic sleep testing company American Sleep Medicine LLC paid a $15.3 million settlement to the federal government after being accused of improper Medicare and TRICARE billing practices. For approximately eight years, the company allegedly submitted Medicare and TRICARE claims requesting reimbursement for services not performed by qualified technicians. The whistleblower that brought forth the allegations received over two million dollars.
In September 2015, the government filed a False Claims suit against Qualium Corporation and Bay Area Sleep Clinics, for allegations of over 14,000 False Claims submissions. The allegations addressed multiple possible violations, including allowing unqualified technicians to perform sleep tests, administering sleep tests at unregistered facilities, requesting reimbursements for unauthorized treatment equipment and deliberately falsifying much of this information on Medicare claims.
A rising problem
As evidenced by recent cases, sleep disorder testing is a hotbed of possibilities for fraudsters. The potential reimbursements are very high, and because sleep disorders like sleep apnea are so common, so is the number of potential patients.
Unfortunately, some sleep labs and sleep specialists seem to be taking advantage of these possibilities, at the expense of their patients.
It may not seem that having unqualified technicians perform sleep tests or lying about where tests are performed could be serious offenses, but sleep disorder diagnoses change people’s lives drastically. The treatment involved can be extensive, cumbersome and intrusive. Patients who do not actually have sleep disorders don't deserve to endure unnecessary treatment, and patients who do have sleep disorders don’t deserve inadequate treatment.
Posted in
