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Sleep Study-Billing for

  1. #1
    Default Sleep Study-Billing for
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    We have a Family Practice doctor that is currently becoming board certified in sleep medicine. The sleep studies will be performed at his clinic. He owns the equipment.

    Can he bill for both performing and reading the test?

    If he performs the test yet pays a flat rate to someone directly to intepret the test, can he bill for both in that scenario as well?

  2. #2
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    Quote Originally Posted by ErrikaKrause View Post
    We have a Family Practice doctor that is currently becoming board certified in sleep medicine. The sleep studies will be performed at his clinic. He owns the equipment.

    Can he bill for both performing and reading the test?

    If he performs the test yet pays a flat rate to someone directly to intepret the test, can he bill for both in that scenario as well?
    Check with Medicare and Medicaid, and the American Academy of Sleep Medicine. Your facility has to be certified as either a sleep lab, or sleep center for insurer's to cover any PSG charges. Sleep labs and Sleep centers have different criteria they must meet to be certified, much like other kinds of labs.

    I'm not sure if the provider can bill for the PSG, because I think that it's a facility charge, but I'm really just guessing - our Sleep Center has a different tax ID than the medical director in charge. Also, he needs to be mindful of where his patients will come from. He can't self-refer without breaking the law. He can bill the interpretation, though, as long as he includes a report.

    Your second scenario is called "pass-through billing". Most insurers prohibit it, including Medicare and Medicaid. Different payers have drastically different coverage guidelines for sleep studies, but most major payers have their medical policies for PSG's online. I would highly suggest for him to get familiar with them, or he'll end up with a billing nightmare.

    Good luck!

  3. #3
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    http://www.aasmnet.org/Articles.aspx?id=1450
    "Social Security Act, § 1877. Specifically, sections 1877(a)(1) and 1877(a)(2) provide that unless exceptions apply, physicians are prohibited from making referrals for furnishing designated health services to entities with which the physicians have financial relationships."

    And here's just an example of how detailed these policies are: here's one from BCBS of TX -
    http://medicalpolicy.hcsc.net/medica...09-08-15#hlink
    Those are just the general requirements. Individual groups and policies can have even stricter coverage requirements.

  4. #4
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    Thanks for the help. I was thinking that was the deal but wanted a second opinion.

    Thanks again!

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