Ways Professional Sleep Study Billing Services Handle HST and PSG Claims

Just because a sleep study was completed, it automatically does not mean that the claim will be payable. From the physician's order to payer remittance, the claim travels through multiple hands. As a result, the final record must clearly reflect this journey in detail. Subsequently, the record must not only show how procedures were performed, but also the physician's note stating the necessity of the service.   

This becomes especially important for sleep study centers that deal with complicated procedures such as home sleep testing (HST) and attended polysomnography (PSG). These two studies assess an individual's sleep pattern, but the billing workflow of these two tests wildly differ. Therefore, professional sleep study billing services have different ways to manage these two different forms of claims.   

Why HST and PSG Claims Require Separate Billing Logic  

Even though HST and PSG tests analyze a person's sleep pattern in order to detect any aberration. However, these two tests follow separate billing logic due to the ways these two tests are conducted.   

While HST is an unattended service that takes place outside the center with the help of portable monitoring devices. PSG, on the other hand, is mostly performed inside a lab with broader physical monitoring, along with an attending technologist.    

Therefore, a biller cannot simply choose a billing process from an appointment description. They need to dive deeper and understand whether the billing is done in a PSG or HST format, respectively.   

Verifying Coverage Before the Test Begins  

A strong claim usually begins much earlier in the billing process. In fact, it begins even before the patient receives the machine or steps inside a laboratory. Before any of this happens, the sleep study billing services in question tend to assess a bunch of details. These include as follows:  

Checking Whether the Ordered Test Fits Payer Policy  

The first thing for a biller to do is to assess which format the payer favors. Even though these two tests share a lot of similarities, some payers tend to prefer one over the other. As a result, providers need to see which test format is favorable, as per the benefit.   

Therefore, the team begins its RCM journey by clearly reviewing the order and the clinical notes before assigning a sleep study format. This review is by no means replacing clinical judgement. This assessment is only meant to see if a proposed service sits well with the payer and its regulations.   

Rechecking the Authorization Details  

Once the preliminary screening is done, the team gradually moves towards authorization assessment. Experienced sleep study billing services know that authorization is a complicated affair, and receiving one is just the tip of the iceberg.   

This is because the approval needs to clearly match details such as the performed procedure, rendering provider, service location, and approved date range. If any of these details change, then the authorization needs to re-appealed.   

Scrubbing the Claim Against the Complete Record  

One of the best parts of hiring professional sleep study billing services is the experience and attention to details. Only an experienced biller understands the essence of a final claim scrubbing and how it can detect small errors that can pass through the billing process. Here is a rundown of all the things that a sleep study biller checks during the final scrubbing of claim:  

• Patient demographics and active insurance  

• Ordering and rendering provider information  

• Authorization number and effective dates  

• Place of service  

• Final procedure and diagnosis codes  

• Applicable modifiers  

• Signed physician order  

• Technologist documentation  

• Scoring summary and interpretation report  

• Test frequency and prior claim history  

Now, some providers can counter that this final step can be completed using an AI model. That might be true, but it is not the complete truth. This model is not only finely tuned but is calibrated to point out billing anomalies with proper human cognizance. As a result, churning out cleaner and more resilient results can stand the test of payers.   

Managing Denials According to Their Actual Cause  

Even though unpaid claims are something that every provider must be concerned about, one needs to understand that not every unpaid claim needs a similar line of response. A demographic rejection might need a corrected claim, while a medical-necessity denial requires a more in-depth clinical note, etc.   

This is where experience comes into play again. Only the most experienced and capable sleep study billing services understand that HST and PSG billing roadblocks come with their own little nuances. Therefore, it is imperative that providers take heed of this and consider outsourcing.  

This is because unlike the internal team, a professional biller does not see denials as an alien entity. They treat denials as part of the process. As a result, they always have a plan for dealing with such a situation. Hence, managing denials according to their actual causes and not with the aid of a pre-determined template.