The U.S. Department of Health and Human Services, Office of Inspector General has identified a number of billing problems with sleep clinics that provide polysomnography services, a type of sleep study used to diagnose obstructive sleep apnea and other sleep disorders.
Some of the billing problems include: billing under inappropriate diagnosis codes; inadequate documentation of services rendered; sleep study services provided by medical staff who lack the proper certifications; and questionable billing patterns.
The amount of money involved is significant. Medicare paid more than $680 million for polysomnography services between 2011 and 2012. In January 2013, one sleep clinic paid $15.3 million to settle allegations that it submitted false claims for sleep studies to Medicare and other government programs. More recently, an OIG audit found that another sleep clinic had submitted more than $1 million in false claims to Medicare for sleep studies.
In the most recent case, OIG found that only 21% of the Medicare claims it reviewed were valid. Fully 79% of the Medicare claims it reviewed were for sleep studies that did not meet Medicare requirements. OIG found that 71% of the claims reviewed did not have adequate supporting documentation; 4% of the claims reviewed involved an attending sleep technician or reviewing physician who did not have the proper certification; and 1% of the claims reviewed involved billing for services that were never actually provided.
Medicare claims for reimbursement of sleep testing must be supported by documentation of a face-to-face clinical evaluation by a treating physician, the patient’s sleep history and symptoms, and a physical examination that documents body mass index, neck circumference, and a focused cardiopulmonary and upper airway evaluation. The failure to maintain adequate documentation may render Medicare claims false for purposes of the False Claims Act.
Depending on the state where the testing occurred, the sleep technician must have appropriate training certifications, such as Registered Polysomnography Technologist or Registered Electroencephalographic Technologist. The raw data from the sleep test must be reviewed and interpreted by a physician with an appropriate sleep certification, such as Diplomate of the American Board of Sleep Medicine. Claims for reimbursement to Medicare are considered false claims if the technician does not have the proper certification or if a physician with the proper certification does not review and interpret the raw data.
If you have evidence that a sleep clinic is submitting false claims to Medicare or another government program, then you should consult with an experienced whistleblower lawyer to protect your rights. You may be entitled to a substantial reward and legal protections as a whistleblower.
To schedule a free and confidential consultation, call John Howley, Esq. at (212) 601-2728.