Dr. Shamiya talks about the challenges of getting sleep studies approved in the U.S., managing reimbursement documentations, the different kinds of sleep medicine practice setups, and the importance of continuous patient management.
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Transcript of the full episode:
Shruti: You have an incredible story. You're born and raised in Gaza, Palestine, and you've dedicated your career to treating sleep disorders in adults and children in the U. S. I'm so grateful you took out time to join me in this conversation. Our listeners want to get to know you a little more. Tell us a bit about how you found your passion for sleep science.
Dr Shamiya: Well, thank you very much first for getting me here and talking to me, well, you know, sleep medicine in general is something that is hidden. It's not something well known all over the world. And it's kind of a mysterious thing for doctors and for patients. They think it's just kind of losing consciousness, that's it.
But we don't know that there's a lot of things going on when you are asleep. I remember when I was in high school, my dad had some issues with his sleep like snoring, but I did not know that this is a kind of a problem. It is just part of sleep. Sometimes I would be worrying what if he's dying when he's sleeping. Hearing a lot of people dying when they are asleep, that made me think.
As far as medical school is concerned, we did not learn a lot about sleep medicine, because it was, as I said, largely unknown. And when even I was a resident here in the U. S., doing my internal medicine, that was also, for us, an unknown topic until I rotated with a neurologist.
And I saw that he is seeing patients for those disorders. And I was surprised that there was a sleep medicine specialty. And at that time, I started to read more about sleep medicine, thinking about it. I was hesitant about that because it was not something famous. At that point, I'd never seen an actual sleep physician except the neurologist.
We did not hear about practices of sleep medicine. There was no clinic, no rotations in sleep medicine during my residency. I heard about sleep apnea, but not to that extent.
Questions like: what are we treating? What is the extent? What can we do? What is the need? But I like the science of it. So that ultimately drove me to sleep medicine. And then I started to learn more about the clinical aspects and I got more excited about sleep medicine from then on. And then, from sleep medicine, I treated myself and treated my son. So that was a great thing for me because at least I figured out what my problem was. And then I saved my son from a bigger problem that he could have develop in the future.
For my son, I think he had a problem since the age of two. But until we did a sleep study and addressed it, most likely he was four.
Shruti: Not a lot of people know about sleep disorders in children. You've written a book, Get Your Sleep Right, which I've read and found to be an excellent primer on sleep disorders and it's also a wonderful resource for patient education for sleep businesses.
You raised some excellent points in the book about the way sleep businesses are set up in the U. S.. Why do we see a general trend here in the U. S. where we see that it's harder than ever to get sleep studies approved? What's happening behind the scenes?
Dr Shamiya: Sleep medicine began with sleep labs and sleep studies. Now it is diverging to sleep management, which means that, like, kind of any practice, there is no cardiologist doing echo, there is no cardiologist doing CAT. So that is not going to survive. Sleep medicine started with studies, but that is not the goal for healthcare, because what is the benefit of a sleep study without managing those patients. So, for insurance, when that happened, a while ago, we were focusing more on sleep studies, reading sleep studies, got a lot of sleep physicians. The insurance spent too much money. And at the same time, there was not too much return because there were no follow ups, no management of those patients.
So, there was a high failure rate in the treatment, foe example in CPAP. Then things start to develop more, and we started to develop more in the CPAP, in the BiPAP, on the masks, even kinds of treatment. We have started to have more alternatives available in the last few years and that is starting to be more of the trend.
They are trying to push more from the management side. Still there are sleep studies, but it is a documentation, so they don't want. So, they just say, go ahead and order the sleep study without knowing why you are doing it and what is the benefit? So, if we are using sleep studies, we must use the them wisely to provide the right sleep disorder treatments.
It is not just that everybody gets in-lab sleep study and a lot of times I see repetition of a study that is not needed, so I think that triggered the alarm for the insurances and they start to decline in general. And that also put us sleep physicians in trouble. It made it harder for us even as a sleep physician to get sleep studies approved because just the abuse of the reimbursements that happened before, led to kind of general block and you must go for a process with denials or now you are known to the insurance, now you are more reasonable for kind of a practice. So that's caused too many problems.
The other thing, they start to go down on the reimbursement, like any kind of procedure. And that's also discouraged a lot, like sleep centers like to do it because the overhead starts to be much higher. So, they cannot survive really.
Shruti: The overheads of the sleep lab just to be a sleep lab by itself. A bit about this in your book too, but for our listeners here who are comprehensive sleep practice owners and managers, can you provide some insights on the point of view of the insurance companies as well? What kind of supportive documents and data are insurance companies looking for when they are assessing a case to give it a decision?
Dr Shamiya: It can vary from insurance to insurance, unfortunately. So, one of our main problems that we don't have is standards of care. Even the ASM, they are very vague about the indication of a sleep study, titration study. So, every insurance created their own thing. And technically they are looking like, if we are talking about the agnostic study, they are looking about the complexity of things.
Why this patient cannot do a homestead study, for example. First, like, let's start with the homestead study. What is the indication of it? Is he snoring, tired, fatigued, sleepy? Has a poor score? the physical exam that supported that this patient could have sleep apnea, the medical problems, comorbidities like heart failure, AFib, strokes, hypertension, obesity, even.
A lot of times when they are ordering a sleep study, all that documentation is not present. There is no evaluation. Just the doctor, maybe like the primary care, say, I think this patient has sleep apnea, but how, what are the symptoms supporting that? So, a lot of times they don't, there is no documentation, which will lead to the insurance to decline.
Now, for in lab sleep studies, it is more complex and usually I recommend that sleep physician to document because it has to be, you have to show the complexity of the case, like there are parasomnias, there are leg movements, there are other things in sleep, not only as a sleep apnea our patient has memory, cognitive impairment, so you cannot just get it approved by just saying, I want to look for a sleep apnea.
They'll say, okay, do a home sleep study. For in lab titration, it varies from insurance to insurance. Sometimes you are looking at the severity of a live patient struggling with claustrophobia, for example, or patient they have, they tried the CPAP, and they are having issues. So, you must document all of that,
To be able to get like for a titration study and some insurances like United Healthcare, whatever you are doing, they are going to decline, keep declining, unless you prove that the patient has hyperventilation and needs a bypass. So, there are huge processes and blocks from the insurances, but in general documentation of symptoms, documentation of a treatment, failure of a treatment, what else you are looking for, that will be the most important.
And unfortunately, all this documentation needs someone experienced in sleep medicine. It cannot just come from non-sleep providers, I will say, because they are not going to think about all of that. They don't have the time even to document all of that. And that will lead to a lot of times rejections of sleep studies. However, it will be indicated in such case, but just the insurance does not have that kind of documentation. And for them, it's going to be easier just to decline and they will know that the other physician, primary care, or cardiologist, they are not going to fight back, and it will go by, and the patient is stuck there.
Shruti: In your book that there are three types of sleep medicine practices in the U. S., could you please briefly tell our listeners what they are and why they should care for continuous patient management?
Dr Shamiya: So, you know, in the sleep practices here, like first we have what we call comprehensive sleep clinic, which means that there is a sleep physician, having their own sleep lab and they are having a whole team dedicated for patients like what we have in Las Vegas Sleep Center. That’s what we created. Like we just treat every patient from zero to 99 years old, all kinds of sleep disorders. So, we run our studies, it is under our supervision, so it is more accurate. We know when it is correct or incorrect when we have to investigate. So, this kind is the best kind of comprehensive treatment, and that's what we need.
And why it is needed, because first, when patient might come, they will not say I have sleep apnea. Patients may present as being tired, fatigued, or they cannot sleep well, or they are sleepy during the day. So, they are looking for their symptoms to improve. Sometimes sleep apnea could be the only problem, sometimes there are other problems.
So, you need to comprehensively treat all sleep disorders so that you can get the results which will treat the symptoms of those patients, because that's what the patient cares about. So, if the patient has insomnia and we do a sleep study and he has sleep apnea, he tried the machine but it's not helping his insomnia, what do you think will happen?
He is not going to complain, and he will stop, and he will not believe in that medicine. So, he just wants medication or, like, other things which can help him. So, being a sleep physician there, seeing the patient in consultation, knows what exactly the sleep disorders are, and saving the patient, because you might not repeat the studies that the patient already has done, and you know where exactly to hit, and treating other sleep disorders.
I think that's what the patient needs. And the continuous follow up is very important because, like, let's say we see patients a lot of times, they start to complain, and then they stop to complain like they gained weight, pressure needs to be changed. They are more tired. They give up on the machine, so we try to find them other solutions.
They had insomnia initially, and we treated it and it improved, but after six months or one year, it came back to them. So, there are a lot of things, and maybe they developed, like, a medical problem, which we discovered from sleep medicine, like patients have started to develop central sleep apnea. He's not controlled in the machine, developing medically from, like, central sleep apnea.
And we figured out he had a stroke, or he had irregularities of the heart. And we are the ones who are triggering those kinds of problems and tell the cardiologist to go ahead. So, see how much we save for that and help the patient.
The other kind of practice is multi-specialty, where there are different clinics, primary, cardiology. They have a sleep lab somewhere else, and Sleep Physician is part of that group. That also means suboptimal, which I will say is not the best way because there is no dedicated team just for sleep. A lot of times, medical assistant helps different providers, so they are not like only focusing on the sleep unless they have dedicated team, which at that time would be good.
Sometimes they have their own sleep labs where they can supervise. Sometimes they are contracted with the hospital or contracted with another place for sleep studies. I usually like the place where everything is done in the same clinic because other than this will facilitate easier for the patients and for the provider.
But in general, if I don't have as a sleep physician control on the quality of the sleep studies, that would be a huge problem because a lot of In lab sleep studies are manually scored. Now, there are some programs that are scoring, but also there is a lot of wrong scoring on that, or there are a lot of missed events. So, it is very important for the physician. So, like if a sleep study comes back negative, and they have a high suspicion of a sleep apnea on a patient, there is something went wrong. So, either my assessment is wrong, or the sleep study is wrong. So, I will go back on that raw data and evaluate the whole data to make sure what is going on. So that would be important.
The third one is like I would call it a part time sleep physician where the physician is like pulmonologist, neurologist, and he is board certified in sleep medicine. Sometimes they have their own sleep labs, sometimes they just sit outside. A lot of those kind of practices grandfathered sleep medicine. They still have some expertise in sleep medicine, but it's not as focused. Honestly, as the other practice where there is a full-time sleep physician fellowship between dedication to treat patients and dedication to his career for, on the sleep medicine.
If there are no sleep physicians available, dedicated at that time, in a lot of places, this is the only way you can get. If someone has expertise in sleep medicine, like a neurologist or a pulmonologist, that they have, experience in managing sleep apnea, or, managing some sleep apnea disorders, they might not manage all sleep disorders like insomnia, resuscitation, narcolepsy, all of that.
So, everybody, every specialty, focuses on what they can do on their own, because if we go back to sleep medicine, it is a combination of different types of medicine, like specialties, and they put it all together to be one specialty. So, part of it is pulmonary, part of it is neurology, part of it is psychiatry, part of it is ENT. So, all of that, they were in sleep medicine and then they put it together and we made fellowship, and we started to be trained focused on what is related to sleep medicine.
So those are the main three types of what we have sleep physician run or sleep expertise. So, you are going to a sleep provider, but there is an independent sleep lab. For example, it is the most common in U.S. to find an independent sleep lab where they don't have a sleep physician. They have a sleep physician as a medical director who reads the sleep studies making about like the accreditation, but they don't see patients. So, the Primary care or cardiologists or however send that for sleep study, they read the sleep study it goes back, and they don't have anything to do with the patient. They don't see or they don't manage those patients and they leave it back to the referring physician.
This kind of practice, I don't think it will survive too long, honestly, because just for the overhead reimbursement and the way how difficult it is. And I don't advise also because the physician who referred and who got the report, doesn't have the experience to manage those patients. So, the patient has to understand, even the providers have to understand what we want from those patients. We want to treat them, or we want just to test them. If we are just testing, that's okay.
But if you want management, that is not the right way because a lot of patients, they even expect it from the sleep tech. They think that is how it goes. And why did he didn't follow up with me? Like I see a lot of patients, I had the sleep studies in the sleep lab, and they would say, oh, I saw the sleep tech and he never managed me.
I told him sleep tech does not manage you. Sleep tech only does sleep study, do his part of job and your primary care supposed must manage you. But unfortunately, he does not have the expertise and we understand that and that has mismanaged a lot of patients.
So, I think honestly if we want to develop It has to be more comprehensive. Those sleep labs must step over to that second level to have a full schedule.
Shruti: What would your advice be for independent sleep centers? What can we do differently?
Dr Shamiya: Yeah, so that's technically the answer, independent sleep labs. So, when we are talking about centers, it might be you're talking independent sleep center, that is a clinic where they have physician, we have like the whole group or, like only independent sleep lab.
So independent sleep lab. I am honestly seeing a lot of sleep labs are losing and they are closing like they are not surviving, and you know, sleep medicine is evolving, and the world is evolving. You now have artificial intelligence that is going to replace a lot of jobs you have. So, you have to match that.
For independent sleep lab, as you are struggling and getting things done, which is not as easy as I said, the only way to do it is to have a comprehensive sleep clinic where they have sleep physician in the same place, seeing patients, consultations, referrals, managing those patients during the sleep studies. You might not be able to stand having a big sleep lab anymore where you have 12 beds or 18 beds, that is not going to be, in general, that much insurance blocking. I see a lot of patients, but I only have three beds and we are using them wisely and to be able to get the patients the right thing. So, they need to step up.
They need to get more new models of treatment that have a comprehensive. That is the only way I think to survive is to have fuller practice If they are able to, because there's not a lot of sleep physicians dedicated for that, and not some sleep physician that will say, I will do my own, why I have to go for a sleep lab? So, if they can get somewhere with that, that would be the best solution.
Running another way is to do home sleep studies. Like more with the home sleep studies, which I see a lot of sleep labs started to transition to that way. But it still is not going to be, for patient, like standpoint. And other non-sleep provider standpoints, they start to look more for the need to help those patients.
Now we are figuring out Alzheimer's is related to sleep apnea. We know that atrial fibrillation is related to sleep apnea and so is heart failure. So, all these medical problems are complex and cause hospitals to lose money causing the health care to have a lot of costs and some from comorbidities and like mortality even rate.
So, I think now the trend is more, as we and as patients are also learning more and more about sleep, and part of it is my book. If you read the book, they will say, hey, I need a sleep physician. And I see that the trend started from patients. They are calling our clinic; they are looking for a sleep physician.
So even if they are initially guided to a sleep lab, to do a sleep study, At the end, they are trying to see a sleep physician to help them out. And now they go back to their doctor, and they'll say, you should do that, and You should go for a sleep physician.
So, I think as the knowledge is more now about what is a sleep physician, what is a sleep lab, and getting more toward that, I think that's what needs to be done. Sleep labs need to be converted to full sleep clinics, treating patients, not only just a diagnosis. Share a few small examples of the steps you've taken to make your own sleep medicine practice more efficient.
Well, one of the things is seeing all patients that need sleep studies. We don't just accept out like if you ever just say, can you do sleep study for a patient? So that helps us for two reasons. One, establishing the patient, explaining to the patient what he has, what we are looking for, how we can help him, and what is the treatment process.
The patient might say from day one, I don't want to do sleep study. Okay, I don't want to go all over this. So, it will be cancelled at that time. We don't like booking because there is one of biggest problems in sleep labs, the no show. So, the patient doesn't show for a sleep study or sometimes they will come, and they will be surprised what they are going through. They will fight with that issue and that is a huge problem created in a lot of situations.
So, when they come for consultation, we rather build the trust between me and the patient, also they understand what they are going through, they see where they are coming and that will help to establish and with that it will also make me to prioritize which patients need sleep studies and what kind of sleep study. There are patients I can do home sleep study and there are patients who need to be in lab sleep study. There is patient I can start with auto CPAP. There are patients who know they need titration study.
Patients start with CPAP, then I switch them like I need titration to confirm or do a home sleep study while they are on the machine or any kind of other treatment. So, all of that will give me What is the plan and how I can approach all those patients? So, it makes it efficient for the patient first by getting them faster because I have prioritization and getting the treatment the way that we can tolerate and helping them out.
Like we have mass fitting, we have other things to help the patient. So all of that, within like, usually what I do, I see the patient, we schedule them for the sleep study, follow up one week after the sleep study, so they are never lost, because in a lot of situations, like if a sleep lab, for example, we did the sleep study, it goes back to primary care, primary care never discuss that, they never had, so the patient might not receive a treatment for months or even years. They never got that treatment.
With this way, I know that the patient is going to follow up. They are going to get the treatment. We follow up after like six weeks, three weeks from getting the machine. We keep following up with the patient. Every six months we follow up with the patient. So, with that, it makes patients the priority. If we need anything, we definitely can do it for the patient. So that is a huge part.
Another part is the staff. Having a good staff is going to make a huge difference because as a physician by myself, I can't leave answering the phones, delivering messages, talking to patients like on the phones all the time, answering their messages.
So having a good staff, a great staff, that they are knowledgeable about sleep. If they are not, you must teach them. If they are not teachable, we can't help because patients are going to call, ask me about the questions, about the machines, about the sleep study, about what is it, why I have to be there even. So, the staff are the first ones who answer the patient and explain to them why we are here, what we do, and that would be the best presentation.
The same for sleep studies, qualities of a sleep study. It's very important because, unfortunately, sometimes unsupervised, or not good supervised, sleep labs can mess up the quality and the trust, those results will be down or can underestimate the patient's severity or can mislead the patient. So, all of that is having the right connection, the right referral.
Okay, let’s say that one of the treatments is oral appliance. So, I know one or two dentists that are certified, and they have great practice. So, I trust those, and I send the patient to them, and I know that they are going to do a good work. So, there are a lot of dentists in different locations, starting to jump in all appliances, not all of them grow being a big company and such thing because not all of them are in real medicine. And they are just like, I want to do the auto plans, get my money and good luck with that. And that's the problem. No, we need dentists who do it and help us manage those patients because they need advancement. There are problems that come with it. They need to own, so it is ownership toward what they did.
The same is with sleep studies and the physician there. They have to ownership those patients as they are going to treat those patients. So, all of those can make efficient practice where you can see the patient, treat them, they are happy, you are happy, and they have very high satisfaction. One of the greatest thing in sleep medicine, I have residents rotating with me, and they are seeing it, is how much the patient rewarding and satisfied and the when they see them first time they are like a groggy grumpy and then when we are following up with them and they are treated and how much does it change their life how much they change their mood that is something like really rewarding so efficient practice to start with the physician seeing physician having a great team. All of that will make it efficient with having timelines, not just a follow-up.
Shruti: What are your thoughts on revenue leakage at sleep centers? Can you give me a few examples of how this may happen and solutions to these issues as well?
Dr Shamiya: Well, the main problem with sleep centers to lose money is to have sleep studies either not reimbursed or patients not showing up. So, for example, a lot of insurances want prior authorization. So, if we don't get the prior authorization correctly, that will result in denying the Sleep Study.
And with that, you're not going to get paid. So that is wrong, you did the work, and you're not getting paid for that. So, it's very important to have an honest person on the prior authorization. And to make sure that every patient has the prior authorization, or even if some insurance say, we don't need the prior authorization, which can happen, then they will tell you where is the prior authorization to have documentation about that. so that is, number one.
Another problem, which I see, and I lost, and I know several sleep labs too, and I was director for another sleep lab, and they lost a lot, is getting the deductible. Sleep studies goes under deductible. So, it is not a regular copayment, nor it is an office visit, so it is a procedure and goes under deductible.
And in a lot of situations, in a lot of sleep labs, they just do the sleep study without telling the patient how much is deductible and how much is their responsibility. They do the study, then they send them a bill. So, guess what will happen, you're not going to see the money, and you're not going to see the patient and good luck to get and sometimes, if you tell them on the night of the study, which will happen because there is no contact before, except, okay, let's schedule, you will get authorization, but they never tell the patient before how much is their responsibility. And then the patient will come in the night, and before going for the study, the technician will tell him, hey, by the way, you have this much.
Guess what will happen? They will start to fight with the technician like nobody told me. They will not pay. They will cancel the study. So, you lost the study, and you lost the patient. So, for us, what I learned and what we do, we try to be as transparent as possible from day one.
We calculate based on what we are seeing of your sleep, of your benefit. This is how much is your responsibility. The patient might say, “I cannot”. Better for me if he says, I cannot, and not come, and I schedule another patient rather than he will say, you don't tell the patient, and you surprise, and then you lose that money. So, this is a second way that losing money.
The third one, which is very common, is none, no show. So, patients just think this is like a game, and it's like just an irregular game, and they don't know that we have limited, like, beds. And they will say, okay, I'm not going to like, I just decided I have a dinner and I don't want to miss out or someone, the family, they don't call and cancel, they don't respect, especially if there are sleep labs that they don't have any relationship with them.
I mean, there is no provider, they don't care if they are going to be seen by a doctor or not. So, at that time, they will just not show, there is no show. And usually, as I said, we get the deductible before. And there is also a fee usually for either scheduling or a fee for no show up and the patient has to sign up to get the credit card.
And I think most of us are doing that or supposed to do that. But that is sometimes a problem. Charge the charge and patients will start to fight back and forth. This is a problem. It is common and it is difficult. It is more difficult than if they don't show up, like what you are going to do, you know.
But that can lead to losing, so instead of having the technician there, and having two patients or three patients, and now if we are losing a patient, which is the actual profit in that patient. So, running a sleep study on one patient is not going to make a profit.
It's a loss for the sleep lab. Having two might have a little bit of profit, but the profit is in their study. And if the patient does not show, then you don't have any profit anymore. So, this makes a lot of loss. The other thing, if it is just a sleep lab, not using the space, because now with the space, overhead is large with the rent and all of that, so if you are close daytime and just nighttime you are working, that is, I mean, you are losing 12 hours that you can use the place for something. And that's where the clinic usually comes in, where you're seeing patients and doing work. This is also a teaching facility.
Shruti: What are your top three messages you want all your resident doctors to take away from you, those who want to go on and have their own sleep labs in the future?
Dr Shamiya: So, the most important thing for the residents, regardless of if they are interested in being a sleep physician or not, the message is, this is the sleep equivalent. This is the sleep lab. Those are the sleep patients. Those are sleep disorders. Is that a fit for you? Is that what you want to do?
For non-sleep, you don't want to go for sleep. The goal is, first, how to detect sleep problems. So, you are a primary care. When to think about it? When to refer for a sleep study? When to refer for a sleep physician? What are the differences? What happens when you get the report? How to look at it? How to help? The main goal is how to help your patient to get the right treatment. Direct those patients, because I'm not expecting primary care or cardiologists or neurologists to treat those patients. But get them the right help.
Get their right, their sleep right. By getting them, directing them correctly where they need to be treated. So, if you have a sleep physician around you, send those patients to the sleep physician. And if you don't have a sleep physician, who's next?
Maybe send him to a pulmonologist or a neurologist that has a knowledge about that. So, at that time they can't help the patient. They don't have but except the sleep labs, which a lot of places they don't have. Only sleep labs, especially in rural areas, don't have sleep physicians. How can you help this patient?
So, looking at his data, looking at the results, you're trying to help him as much as you can because you are the only helper. And if not, maybe he needs to go. Somewhere, even if it is far, and he needs to seek help or get to telemedicine and get help from a sleep physician. So, that is the main goal, and we understand it, by the end of the rotation, usually, very well.
Shruti: At Aarogram we believe that being efficient in your business as a healthcare provider also means providing more patient centric care, like you spoke about. Therefore, we ask this question to every guest on our podcast, and this is a fun one. What's the most ridiculous or witty way in which you have solved a workflow problem at your healthcare setting, at your practice?
Dr Shamiya: Well, the unfortunate and ridiculous problem is when patients have no shows. I mean, we have a strict policy and we either, discharge them from Declan so they will not come back. So, but I would not say this ridiculous, this something is needed.
I'll give them a cup of coffee and try to make them happy. Or a lot of things, like maybe the simplest thing, I prescribed for patients and patients will be surprised just to go outside in the sun. So, when they are tired, fatigued during the day and they have insomnia or hypersomnia, the simplest thing after them in the morning is to go outside for half an hour. Every couple of hours, go 5, 10 minutes and they would look at me and say, it makes sense. But we never thought about that. But I did. This is nature, maybe there's a treatment if they are grumpy.
Shruti: Thank you so much for this informative chat. Thank you so much for taking out time for this. It was wonderful having you on our podcast. Thank you.
Dr Shamiya: Thank you very much.