Insurers change coverage for skyrocketing sleep apnea costs

Since doctors increasingly are diagnosing their patients with sleep apnea, insurers' apnea-related costs have skyrocketed, prompting some to change their coverage policies for the disorder.

A sleep apnea diagnosis usually requires patients undergo tests overnight in a sleep lab; some patients spend two nights in the lab to separately test for sleep apnea and to try a continuous positive airway pressure (CPAP) machine. Insurers often spend $1,900 for one overnight stay, reported the NPR Shots blog.

As a result of this increased spending, some experts are concerned that overnight tests to diagnose apnea are over-prescribed. Medicare payments for sleep testing increased from $62 million in 2001 to $235 million in 2009.

This contrasts effective home sleep tests that cost less than a fifth of the lab version. Although Medicare began paying for home sleep tests in 2008, the tests have had only modest growth.

"I believe lab tests, as opposed to the home tests, are being wildly overprescribed," said Michael Backus, senior vice president of WellPoint subsidiary American Imaging Management. "It should be 70 percent at home and 30 percent in the lab."

To curb rising costs, WellPoint has begun changing how it pays for sleep testing by, for example, requiring special pre-authorizations before approving overnight stays and determining whether patients qualify for home sleep tests, NPR Shots noted.

Another problem, according to Blue Cross Blue Shield of North Carolina Medical Director Fred Holt, is some patients don't first undergo basic exams before overnight lab tests so they're being prescribed expensive tests they don't necessarily need. In other cases, labs are prescribing CPAP machines without suggesting less costly strategies, such as losing weight or sleeping on one's side.

"We are spending more and more money on sleep testing and treatment, and like anything else in healthcare, there are unscrupulous people out there who are more than happy to do testing and treatment that might be of questionable value," Holt said. "This might be because of naiveté on the part of the physician, or unfortunately, it could be done for the sake of improving the cash flow of the business."

To learn more:
- read the NPR Shots blog

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