Sleep Solutions: Home Sleep Tests Billed as Attended Studies

Sleep Solutions paid $500,000 in a 2010 settlement over allegations that it billed home sleep tests as studies attended by a sleep technologist. The Justice Department said the company also billed those tests when TRICARE and the Federal Employees Health Benefit Program did not reimburse in-home studies. For someone who supplied the kits, worked with the recordings or handled the claims, the case turns on a recognizable difference between the service the patient used and the service the bill described.

Sleep Solutions, Inc. was a diagnostic service provider in Glen Burnie, Maryland, supplying self-administered kits to evaluate sleep-disordered breathing. The company denied the allegations, and the payment settled the government’s False Claims Act claims.

What the Home Kit Supplied and the Bill Represented

Sleep Solutions supplied a test the patient administered at home, while the Justice Department alleged that the company billed an attended service to increase reimbursement. We see a home kit getting a staffing upgrade on paper.

The Centers for Medicare & Medicaid Services explained that distinction in its March 3, 2009 sleep-testing decision memo. It describes attended laboratory polysomnography as a recording supervised by a technologist during sleep, with the ability to intervene when needed. That is work performed while the signals are being collected, not simply a review of the finished recording.

The same memo describes portable monitors used in both attended and unattended settings. Some record sleep staging as well as breathing-related signals, while others record a narrower set of signals. The equipment and the attendance are separate parts of the service description: a portable device’s capabilities do not tell you who was present while it recorded.

Reviewing a Home Recording Does Not Supply Attendance

Professional review can follow an unattended home recording. The clinical guidelines reproduced in the CMS memo call for a technologist or technician to apply the sensors or teach the patient how to apply them, and for a qualified sleep specialist to review the raw data. They still describe the home recording as unattended.

The same guidance calls for a device that displays raw data and allows manual scoring or editing of automated scoring. A completed report therefore sits at the end of several kinds of work: acquiring the signals, scoring them and reviewing them.

A worker who sees a recording and a final report may know exactly when each part of the service happened. Instructions before the test and interpretation afterward do not place a technologist in attendance during the recording.

Billing TRICARE for Home Studies It Did Not Cover

The Justice Department alleged that Sleep Solutions billed TRICARE and the Federal Employees Health Benefit Program for home studies during periods when those programs did not permit reimbursement. Its announcement concerned payment for the same self-administered studies, not just the claim that a technologist attended them.

That allegation reaches a different payment decision from the attended-service allegation. One concerns the service described on the claim. The other concerns whether the program paid for the home service at the time it was performed. An insider who knows the actual test and the payer can connect those questions to the same bill.

For a biller handling several programs, the payer is part of the story alongside the test and its date. The public health care money in this case came through programs the Justice Department alleged did not cover the home service when billed.

A Later Home-Test Billing Case at Coastal

The same difference between home testing and a more expensive represented service appears in the separate Coastal Diagnostic Testing Group case. In its account of the owner’s criminal guilty plea, the Justice Department described admitted overcharging for studies performed at home as more expensive in-office studies. It also described instructions to bill for studies that did not occur.

The parallel gives a kit coordinator or biller a concrete distinction to recognize: a test performed at home and a test never performed leave different operational histories. The account of Coastal’s owner’s plea describes both practices, while the Sleep Solutions settlement addressed allegations about self-administered tests. Knowing whether a device reached a patient, whether a recording came back and what service was billed connects the clinical workflow to the money.

What a Sleep-Testing Insider Can Connect

The home-testing workflow gives different employees different views of the same service. Device assignment and instruction concern what reached the patient, the recording concerns what the equipment captured, and review and interpretation concern what happened to the data afterward. The claim adds the service description, date, location and payer.

A device assignment, a test date and a completed interpretation mark different events. The Veterans Affairs REVAMP home-testing manual separately tracks device identity, assignment, shipping, return, test date, download, interpretation and failed testing. For someone coordinating kits, those distinctions are the daily work behind the final report. They can help explain whether the claim describes what happened to that patient’s test.

Staffing records tell another part of the story. In a facility, the workflow includes staff assignment and attendance during acquisition; in the home pathway, it follows the patient’s recording and the later return or upload. Someone working across scheduling and billing can connect the people assigned to a study with the service claimed for it. The equipment’s journey and the staff’s work are concrete evidence of the difference at the center of the Sleep Solutions allegation.

We work with the person who can connect those records to the decision to bill an attended study. Your knowledge of how the service actually ran can explain a mismatch that a claim description alone conceals. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know What Happened During the Test

If you worked with home-test kits, recordings or claims that described an attended service, speak to one of our whistleblower experts about the attended-test billing you saw. We build the case with you and bring in healthcare fraud whistleblower lawyers who understand sleep-testing claims and the payer’s rules. We stay beside you as we turn your knowledge of the testing into your strongest sleep-testing whistleblower case.