Oct 28, 2024 | | 0 |
Software solutions allow sleep techs to score hypopneas smarter by streamlining the dual-scoring process required for Medicare versus private insurers.
By Lindsey Nolen
Sleep techs in the United States face a frustrating dilemma that their counterparts in other countries don’t: having to score sleep studies twice due to differing insurance criteria for what counts as a hypopnea.
The dual scoring uses valuable time and strains already-thin resources. Fortunately, sleep study scoring software solutions are stepping in to streamline this process, allowing sleep labs to keep pace without burning out their teams.
Hypopnea Criteria: Private Insurance Versus Medicare
Hypopneas, part of the commonly used apnea-hypopnea index (AHI) for sleep apnea diagnosis, are defined differently in the United States depending on a patient’s insurance. The American Academy of Sleep Medicine (AASM) and private insurers use a 3% oxygen desaturation threshold for scoring hypopneas in adults.1 But the Centers for Medicare and Medicaid Services (CMS) requires a higher threshold of a 4% oxygen desaturation to score an event as a hypopnea.2
Patients who meet the criteria for sleep apnea under the 3% but not the 4% threshold can be put in a difficult position—a not uncommon situation when patients transition from private insurance to Medicare at age 65.
Urgency for New Medicare Beneficiaries
The problem is becoming more urgent as Baby Boomers retire and transition to Medicare coverage.
“It unfortunately leads to poor care,” says neurologist-sleep specialist Raman K. Malhotra, MD, FAASM, a former president of the AASM. “They may have had coverage for their CPAP supplies and a machine with previous insurance, and now, when they transition to Medicare, they not only don’t have coverage for something that they may be already benefiting from, but it may require another sleep study.”
Andrea Ramberg, CCSH, RPSGT, clinical director at sleep scoring software company EnsoData, says, “Patients who were never scored at the 4% desaturation criteria will require a new sleep test once they are on Medicare…even those who have been on CPAP treatment successfully for years.” She adds that these patients must sleep without their CPAP to satisfy insurance requirements for a sleep study.
“For sleep labs that don’t require testing to offer dual-scoring criteria up front, it can be very cumbersome and time-consuming on clinical staff, likely doubling the scoring and reporting workload. This leads to growing backlogs and the need to deprioritize other areas of need in the sleep lab,” Ramberg says.
Using an automated dual-scoring solution can reduce the risk of human error when manually switching between scoring criteria.
Related Read for You:
OIG Report: Most Medicare Claims for Replacement CPAP Supplies Didn’t Comply with Requirements
Software Solutions for Streamlined Hypopnea Scoring
In response, sleep study scoring software companies have developed innovative solutions to streamline hypopnea scoring, allowing techs to score studies once while automatically applying both the 3% and 4% criteria.
“At the time it was first instituted, sleep labs had to find workarounds to correctly report indices based on insurance requirements,” says Brad Dotson, BS, RRT, RPSGT, director of sales and marketing at Neurotronics LLC, a subsidiary of Nihon Kohden. Sleep techs using Nihon Kohden Polysmith software would manually score 4% hypopneas by designating a custom event.
Now, ”Nihon Kohden’s Polysmith sleep software includes features specific to scoring and reporting both 3% and 4% hypopnea events and associated indices,” Dotson says, automatically linking each event with the proper index based on its desaturation level.
Neurovirtual also automates dual-scoring, a software feature that has become much more popular among sleep labs lately, according to Felipe Lerida, RPSGT, clinical product manager at Neurovirtual, who says 80% of new Neurovirtual clients request the feature be turned on, up from about 20% a few years ago. Many labs that previously opted out are now requesting the feature be activated in their software.
“When Neurovirtual’s software scores a hypopnea, it checks if there’s a desaturation there, confirms whether 3% or 4%, and classifies it accordingly. So the sleep tech just scores a hypopnea; they don’t have to say whether it’s a 3% or a 4%,” Lerida says.
Cadwell has offered a dual-scoring capability in its Easy III PSG software since 2017. “We recommend users only score the record according to AASM criteria (single-scoring) and mark all hypopneas that have a 3% and/or associated arousal,” says James Blevins, RPSGT, product manager of sleep diagnostics at Cadwell. “From there, we can display both the AASM’s recommended AHI, as well as the Medicare-compliant AHI.” By default, the software displays both, but “some labs may opt to customize reports with a report that shows only the AASM or only the Medicare values,” Blevins says.
EnsoData’s AI-based solutions for both in-lab and home sleep studies feature a toggleable switch in EnsoSleep Study Management, which allows the user to see the scored study at 3% and 4% with a single click.
Downsides to Automating Dual Scoring
A pain point of automated dual scoring is patient confusion when they see different scores on their sleep study report. This is particularly problematic if patients skim the results in an online portal before a clinician can directly explain the results, potentially leading to misunderstandings about diagnosis and treatment options.
“It is very hard to tell a patient they have sleep-disordered breathing but their insurance will not pay for their therapy,” Ramberg says.
To tackle this, clinicians should develop clear communication strategies to explain the dual-scoring system before patients ever have a chance to see their results.
Also, Chad Doucette, vice president of sales and marketing at sleep study scoring company Sleep Strategies Inc, says, “Just as an automatic pilot requires a skilled pilot to take off and land the plane, we still need qualified technologists to review and validate the scoring results.”
Beyond software solutions, Doucette says establishing standardized protocols ensures consistency in scoring. According to Doucette, this includes regular audits, comparing techs’ work, and using blind scoring. “Enrolling all scoring technologists in the AASM Inter-scorer Reliability program further enhances consistency, ensuring everyone follows the same guidelines,” he says. “This promotes high-quality data and better patient outcomes.”
Wish for Standardization
However, the ultimate goal for many in the field is the standardization of scoring criteria across insurance providers.
“It would greatly benefit everyone if all payors could accept the clinical standard endorsed by the AASM as the most accurate,” says Cadwell’s Blevins. “Achieving a consensus on a single clinical standard among payor industry standards would represent a significant improvement for all.”
Until such standardization occurs, sleep professionals will continue to rely on innovative software solutions to navigate the complexities of dual-scoring criteria. By adopting these advanced systems, labs can ensure they’re providing the best possible care to patients while managing their resources efficiently.
