I was recently contacted by a non-physician regarding how to find a medical director for a sleep lab she is opening. This sleep lab is not in my state (Mississippi). Here is my answer to her:
You can try advertising- either on the American Academy of Sleep Medicine Job Board, or in one of the sleep journals (either "Sleep" or "The Journal of Clincal Sleep Medicine"). You can also post the position at the Annual Sleep Meeting.
Another option is calling sleep physicians in your state (medical directors of existing sleep labs) and asking them if they are interested in being medical director of your sleep lab.
Showing posts with label sleep labs. Show all posts
Showing posts with label sleep labs. Show all posts
Monday, November 01, 2010
Thursday, November 19, 2009
Sleep Center Accreditation
Sleep Review magazine's November issue is now available online.
It has an article about accreditation; I agree with every word of it:
http://www.sleepreviewmag.com/issues/articles/2009-11_02.asp
It has an article about accreditation; I agree with every word of it:
http://www.sleepreviewmag.com/issues/articles/2009-11_02.asp
Thursday, September 04, 2008
Patient Problems at Sleep Labs
A reader commented:
"The problems of sleep labs are not just compliance with regulations. Sleep lab operators need to run good facilities which are tolerable for patients. It took me a long time to recover from the emotional torment of lousy techs who answer every question "you would have to ask your doctor." Insurance companies pay through the nose for the testing, but there is never a doctor available to help the hapless patient. When I couldn't fall asleep during titration and asked for sleeping pills, the tech said he would ask a supervisor, the supervisor hummed and hawed "What kind of meds did you bring with you?" "None, " I said, "never needed any." "Then I will call the doctor, maybe we can get some presecribed for you for tonight." When the doctor did not call back, she said "He hasn't called, but actually you were sleeping beautifully for nearly 3 hours you just woke up a few minutes agao and began calling out for help, which is why I came in!"
Thanks for reading. Actually, the problem is with government regulation. From your description I am assuming that sleep center you went to was an Independent Diagnostic and Testing Facility (IDTF)- a slight majority of sleep centers are IDTF's as opposed to hospital-associated sleep centers or sleep centers that are an extension of a physician practice.
Somnus sleep clinic, which I am a minority owner of, is an IDTF. Because of anti-kickback rules, only a minority of patients can see me prior to the sleep study. Government regulations require a majority of patients to be referred by an outside physician directly for a sleep study.
As medical director, I am available to the technicians for patient emergencies. However, if the techs call me in the middle of the night for a directly referred patient who can't sleep, it puts me in a legally awkward situation of giving a medication to someone who is not my patient. And where is the sleeping pill supposed to come from? Should I call in a prescription to an all-night pharmacy and have the patient drive to go get it (with all the electrodes pasted in their hair)? I guess I could give them one of the samples from my private practice- however new CMS (Medicare) regulations that take effect Jan 1 2009 put new restrictions on the interactions between physicians and IDTF's.
If all of this seems confusing to you, I would encourage you to look through the archives and look at my posts on management of a sleep lab and ownership of a sleep lab.
And technicians are supposed to tell you to ask your doctor about any medical inquiries.
If any sleep physicians out there who practice in IDTF's or hospital-associated sleep labs have a solution for patient requests for hypnotics, I'd be interested in hearing them.
"The problems of sleep labs are not just compliance with regulations. Sleep lab operators need to run good facilities which are tolerable for patients. It took me a long time to recover from the emotional torment of lousy techs who answer every question "you would have to ask your doctor." Insurance companies pay through the nose for the testing, but there is never a doctor available to help the hapless patient. When I couldn't fall asleep during titration and asked for sleeping pills, the tech said he would ask a supervisor, the supervisor hummed and hawed "What kind of meds did you bring with you?" "None, " I said, "never needed any." "Then I will call the doctor, maybe we can get some presecribed for you for tonight." When the doctor did not call back, she said "He hasn't called, but actually you were sleeping beautifully for nearly 3 hours you just woke up a few minutes agao and began calling out for help, which is why I came in!"
Thanks for reading. Actually, the problem is with government regulation. From your description I am assuming that sleep center you went to was an Independent Diagnostic and Testing Facility (IDTF)- a slight majority of sleep centers are IDTF's as opposed to hospital-associated sleep centers or sleep centers that are an extension of a physician practice.
Somnus sleep clinic, which I am a minority owner of, is an IDTF. Because of anti-kickback rules, only a minority of patients can see me prior to the sleep study. Government regulations require a majority of patients to be referred by an outside physician directly for a sleep study.
As medical director, I am available to the technicians for patient emergencies. However, if the techs call me in the middle of the night for a directly referred patient who can't sleep, it puts me in a legally awkward situation of giving a medication to someone who is not my patient. And where is the sleeping pill supposed to come from? Should I call in a prescription to an all-night pharmacy and have the patient drive to go get it (with all the electrodes pasted in their hair)? I guess I could give them one of the samples from my private practice- however new CMS (Medicare) regulations that take effect Jan 1 2009 put new restrictions on the interactions between physicians and IDTF's.
If all of this seems confusing to you, I would encourage you to look through the archives and look at my posts on management of a sleep lab and ownership of a sleep lab.
And technicians are supposed to tell you to ask your doctor about any medical inquiries.
If any sleep physicians out there who practice in IDTF's or hospital-associated sleep labs have a solution for patient requests for hypnotics, I'd be interested in hearing them.
Friday, June 27, 2008
Running A Sleep Lab
A key part of running a sleep lab is keeping on top of the constantly changing regulatory environment, on both the federal and state levels. This link does a good job of describing the new federal regulations for independent diagnostic and testing facilites (IDTF's) that went into effect January 2008 (though for pre-existing IDTF's, many of the provisions do not apply until January 2009). Every February the AASM gives a course on sleep lab management that is very useful for anyone running a sleep lab.
Tuesday, April 29, 2008
Starting a Sleep Lab, part three
There are 3 basic types of sleep labs: hospital associated, extension of a physician practice, and independent diagnostic and testing facility (IDTF).
Assuming that a physician is not starting a sleep lab in association with a hospital, the basic choice comes down to IDTF or extension of a physician practice.
In my case, I started Somnus Sleep Clinic with some non-physician owners, so IDTF was the only option.
For a physician or physician group, either form could be appropriate. The key difference is how patients are referred to the sleep lab.
For an IDTF, the Feds mandate that most of the referrals for sleep studies come from outside physicians. Practically, what this means is that the outside physicians refer the patients directly for the sleep study. The sleep physician then sees the patient (if the patient is going to be seen by the sleep physician) after the sleep study (within 3 months will meet AASM guidelines). You need to put some type of statement on the psg order form (which should be signed by the outside referring physician) that a cpap titration will be performed if clinically appropriate- then both studies will count as ordered by the outside physician.
For a sleep lab that is an extension of a physician practice, most of the sleep study referrals (85% is a figure I've heard several times before) need to come from inside the practice. Practically, what this means is that the sleep studies need to come from either the practice's own patients and/or patients referred to the practice for a sleep evaluation (and seen by the practice prior to the sleep study). The order for the sleep study needs to come from a physician in the practice.
There are some other differences between IDTF's and physician practice sleep labs, more to come later.
Assuming that a physician is not starting a sleep lab in association with a hospital, the basic choice comes down to IDTF or extension of a physician practice.
In my case, I started Somnus Sleep Clinic with some non-physician owners, so IDTF was the only option.
For a physician or physician group, either form could be appropriate. The key difference is how patients are referred to the sleep lab.
For an IDTF, the Feds mandate that most of the referrals for sleep studies come from outside physicians. Practically, what this means is that the outside physicians refer the patients directly for the sleep study. The sleep physician then sees the patient (if the patient is going to be seen by the sleep physician) after the sleep study (within 3 months will meet AASM guidelines). You need to put some type of statement on the psg order form (which should be signed by the outside referring physician) that a cpap titration will be performed if clinically appropriate- then both studies will count as ordered by the outside physician.
For a sleep lab that is an extension of a physician practice, most of the sleep study referrals (85% is a figure I've heard several times before) need to come from inside the practice. Practically, what this means is that the sleep studies need to come from either the practice's own patients and/or patients referred to the practice for a sleep evaluation (and seen by the practice prior to the sleep study). The order for the sleep study needs to come from a physician in the practice.
There are some other differences between IDTF's and physician practice sleep labs, more to come later.
Thursday, April 03, 2008
Starting a Sleep Lab, part two
Yesterday, I briefly touched upon the necessity of having patients for your sleep lab. And I am not talking about patients with restless legs or insomnia. Though I find those 2 conditions interesting and challenging to treat, they will not generate a large number of sleep studies. You can't support a million dollar sleep lab billing evaluation and management codes for insomnia!
So where will the sleep apnea patients, the bread and butter of sleep medicine come from?
If you are a pulmonlogist and part of a pulmonary group, you have a head start. If you are a psychiatrist/neurologist/non-pulm internist/FP, read on.
Most likely you will need to be part of a "network/association," and I use these words loosely and am not implying an insurance network. Let me give some examples:
1. You could run a sleep lab for a large multi-specialty group, and get referrals from the physicians in the group. If you choose this route, you will most likely get the professional fee for reading the studies, while the profit from the technical component will go to the group as a whole.
2. You could associate yourself with a hospital, perhaps formally and either be employed by the hospital or you could own the sleep lab with the hosptial as a joint venture. Alternatively you could have a less formal association with the hospital (perhaps do ER call for your primary specialty for the hospital with the understanding that sleep patients from the hospital will be directed to your private sleep lab). If you are associated with a hospital, either formally or informally, you can get referrals from other doctors/groups associated with the hospital.
3. You could sell part of your sleep lab to local physician groups (primarily IM/FP, but also cards, ENT). This strategy can work both in the initial stages of starting a sleep lab or for an established sleep lab.
disclaimer: before putting any of these ideas into practice, consult an attorney. Stark doesn't apply to sleep labs (though it does apply to DME), but anti-Kickback rules do.
ADVERTISING: You probably need to do some advertising to patients, but don't rely on this to generate a large number of sleep studies. And aim your advertising towards osa, not insomnia. More important than advertising to patients is hiring someone to promote your sleep practice to other physicians (this can be done on a part-time basis).
More later..
So where will the sleep apnea patients, the bread and butter of sleep medicine come from?
If you are a pulmonlogist and part of a pulmonary group, you have a head start. If you are a psychiatrist/neurologist/non-pulm internist/FP, read on.
Most likely you will need to be part of a "network/association," and I use these words loosely and am not implying an insurance network. Let me give some examples:
1. You could run a sleep lab for a large multi-specialty group, and get referrals from the physicians in the group. If you choose this route, you will most likely get the professional fee for reading the studies, while the profit from the technical component will go to the group as a whole.
2. You could associate yourself with a hospital, perhaps formally and either be employed by the hospital or you could own the sleep lab with the hosptial as a joint venture. Alternatively you could have a less formal association with the hospital (perhaps do ER call for your primary specialty for the hospital with the understanding that sleep patients from the hospital will be directed to your private sleep lab). If you are associated with a hospital, either formally or informally, you can get referrals from other doctors/groups associated with the hospital.
3. You could sell part of your sleep lab to local physician groups (primarily IM/FP, but also cards, ENT). This strategy can work both in the initial stages of starting a sleep lab or for an established sleep lab.
disclaimer: before putting any of these ideas into practice, consult an attorney. Stark doesn't apply to sleep labs (though it does apply to DME), but anti-Kickback rules do.
ADVERTISING: You probably need to do some advertising to patients, but don't rely on this to generate a large number of sleep studies. And aim your advertising towards osa, not insomnia. More important than advertising to patients is hiring someone to promote your sleep practice to other physicians (this can be done on a part-time basis).
More later..
Wednesday, April 02, 2008
Starting a Sleep Lab, part one
I have had several physicians email/call/PM me recently about how to start a sleep lab, and whether it is still possible with the new CMS decision on home testing.
Regarding home testing: this will have a negative financial impact on sleep physicians, but I don't think it precludes a physician from starting a sleep lab. A lot is still up in the air, however, and the full financial implications of home testing are uncertain.
Even before the CMS decision, starting a sleep lab was a difficult process. I would encourage any physician (or technician or business person) who is interested in starting a sleep lab to attend the annual February American Academy of Sleep Medicine Management Course (see the AASM website for details).
Some things for a physician to think about in starting a sleep lab:
1. Where are the patients going to come from? If you are a pulomonologist and part of a pulmonary group, your group can probably generate enough sleep patients to sustain a sleep lab (roughly 1 sleep bed/pulmonologist). If you are a solo psychiatrist or neurologist, things are going to be tough.
2. Are you established in an area? It's easier to start a sleep lab if you are already a practicing physician in an area and a member of insurance networks.
3. Do you have a million dollars sitting around? The start-up costs for a 6 bed sleep lab are $500,000 to 1 million.
4. Who's going to manage the lab (hire/train technicians, get the lab in network/accredited, etc)? There are companies that you can work with in this regard. There are several companies that both own sleep labs and that partner with physicians and hospitals to run sleep labs- United Sleep Medicine, SleepWorks.
5. Don't even think about becoming involved in DME if you are an inexperienced physician just coming out of sleep fellowship. If you do eventually get involved in DME, make sure the situation is reviewed by a lawyer who is knowledgeable about Stark/anti-kickback rules.
More later.
Regarding home testing: this will have a negative financial impact on sleep physicians, but I don't think it precludes a physician from starting a sleep lab. A lot is still up in the air, however, and the full financial implications of home testing are uncertain.
Even before the CMS decision, starting a sleep lab was a difficult process. I would encourage any physician (or technician or business person) who is interested in starting a sleep lab to attend the annual February American Academy of Sleep Medicine Management Course (see the AASM website for details).
Some things for a physician to think about in starting a sleep lab:
1. Where are the patients going to come from? If you are a pulomonologist and part of a pulmonary group, your group can probably generate enough sleep patients to sustain a sleep lab (roughly 1 sleep bed/pulmonologist). If you are a solo psychiatrist or neurologist, things are going to be tough.
2. Are you established in an area? It's easier to start a sleep lab if you are already a practicing physician in an area and a member of insurance networks.
3. Do you have a million dollars sitting around? The start-up costs for a 6 bed sleep lab are $500,000 to 1 million.
4. Who's going to manage the lab (hire/train technicians, get the lab in network/accredited, etc)? There are companies that you can work with in this regard. There are several companies that both own sleep labs and that partner with physicians and hospitals to run sleep labs- United Sleep Medicine, SleepWorks.
5. Don't even think about becoming involved in DME if you are an inexperienced physician just coming out of sleep fellowship. If you do eventually get involved in DME, make sure the situation is reviewed by a lawyer who is knowledgeable about Stark/anti-kickback rules.
More later.
Thursday, February 21, 2008
The decline of physician-practice sleep labs
There are 3 basic business structures of sleep labs:
1. hospital-owned
2. independent diagnostic and testing facility (IDTF's)
3. extension of a physician practice
At the AASM Sleep Management course I went to in February, it was reported that business structure 3 comprised less than 5% of sleep labs. The differences between the 3 business structures can be complex, and I plan to talk about this more in future posts. To briefly illustrate the complexity, I will just mention at this time that physicians are often part-owners of IDTF's and hospital associated sleep labs. Physicians sometimes fully own an IDTF.
In my brief career in sleep medicine, the decline of stucture #3 has been a disturbing trend. Sleep Review Magazine reports on how a new interpretation of an old Florida law has led to severe restriction on this type of lab:
In responding to a request from Jacksonville Heart Center (Jax Heart), the State of Florida Board of Medicine finds that physicians of physician-owned labs must directly supervise sleep studies.
In its request, Jax Heart, a group practice comprised of 17 cardiovascular physicians, proposed to establish an eight-bed sleep center as part of its medical practice. The request stated, in part, “.... For sleep studies performed after normal business hours, a Jax Heart physician would be on-call and immediately available by phone."
.....the main issue with the request submitted by Jax Heart was whether the sleep center’s services were being conducted under the “direct supervision” of Jax Heart.
The State of Florida Board of Medicine stated, “If the Sleep Center does provide services under the direct supervision of Jax Heart, the Petitioner’s proposed arrangement does not constitute a ‘referral’ that is precluded by Section 458.053(5), Florida Statutes.
“We found that the law dictated that patients needing a sleep study would be supervised differently depending upon whether the lab was owned by a physician group rather than an IDTF/Hospital,” said Masters.
Ultimately, the Board found that Jax Heart would not be providing services under the “direct supervision” (meaning supervision by a physician who is present in the office suite and immediately available to provide assistance and direction throughout the time services are being performed), and that Jax Heart’s proposed referral of patients to its sleep center is precluded by Section 458.053(5), Florida Statutes.
“It is also important to note that the declaratory statement did not say that physicians are not able to own their own lab—rather that they must provide direct supervision for patient care in a sleep center,” Masters said. “Secondly, the Board reinforced that physician-owned sleep labs must only treat their patients in the sleep center. This provision would not change even if the Direct Supervision requirement was changed to be an exception.”
Read the entire decision here.
Basically, the state of Florida is requiring sleep labs that are an extension of a physician practice to have a physician present whenever sleep studies are run. This is a poorly written article; as I pointed out above, a physician can own all or part of an IDTF. There is a definite distinction between a physician-owned sleep lab and a sleep lab that is an extension of a physician practice.
1. hospital-owned
2. independent diagnostic and testing facility (IDTF's)
3. extension of a physician practice
At the AASM Sleep Management course I went to in February, it was reported that business structure 3 comprised less than 5% of sleep labs. The differences between the 3 business structures can be complex, and I plan to talk about this more in future posts. To briefly illustrate the complexity, I will just mention at this time that physicians are often part-owners of IDTF's and hospital associated sleep labs. Physicians sometimes fully own an IDTF.
In my brief career in sleep medicine, the decline of stucture #3 has been a disturbing trend. Sleep Review Magazine reports on how a new interpretation of an old Florida law has led to severe restriction on this type of lab:
In responding to a request from Jacksonville Heart Center (Jax Heart), the State of Florida Board of Medicine finds that physicians of physician-owned labs must directly supervise sleep studies.
In its request, Jax Heart, a group practice comprised of 17 cardiovascular physicians, proposed to establish an eight-bed sleep center as part of its medical practice. The request stated, in part, “.... For sleep studies performed after normal business hours, a Jax Heart physician would be on-call and immediately available by phone."
.....the main issue with the request submitted by Jax Heart was whether the sleep center’s services were being conducted under the “direct supervision” of Jax Heart.
The State of Florida Board of Medicine stated, “If the Sleep Center does provide services under the direct supervision of Jax Heart, the Petitioner’s proposed arrangement does not constitute a ‘referral’ that is precluded by Section 458.053(5), Florida Statutes.
“We found that the law dictated that patients needing a sleep study would be supervised differently depending upon whether the lab was owned by a physician group rather than an IDTF/Hospital,” said Masters.
Ultimately, the Board found that Jax Heart would not be providing services under the “direct supervision” (meaning supervision by a physician who is present in the office suite and immediately available to provide assistance and direction throughout the time services are being performed), and that Jax Heart’s proposed referral of patients to its sleep center is precluded by Section 458.053(5), Florida Statutes.
“It is also important to note that the declaratory statement did not say that physicians are not able to own their own lab—rather that they must provide direct supervision for patient care in a sleep center,” Masters said. “Secondly, the Board reinforced that physician-owned sleep labs must only treat their patients in the sleep center. This provision would not change even if the Direct Supervision requirement was changed to be an exception.”
Read the entire decision here.
Basically, the state of Florida is requiring sleep labs that are an extension of a physician practice to have a physician present whenever sleep studies are run. This is a poorly written article; as I pointed out above, a physician can own all or part of an IDTF. There is a definite distinction between a physician-owned sleep lab and a sleep lab that is an extension of a physician practice.
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