As an early career cardiologist, it is challenging to recognize the complex intricacies of coverage and reimbursement. Although an in-depth review is beyond the scope of this article, our intent is to highlight some essential points.

WHAT IS COVERAGE?

The goal of insurance coverage is to provide quality health care in an affordable, sustainable and cost-effective manner. For covered services, a third party will pay either in whole or in part for medical services. Coverage policies are national guidelines generated by different payers to state and local sub-entities to guide local coverage, but not to dictate. Due to the independence of local and state entities, coverage remains variable from one region to the next, and even locally under the same national policy.  

Medicare coverage is paramount, as it drives coverage decisions by private insurers due to the expansive size and scope of Medicare. The Centers for Medicare and Medicaid Services (CMS) issues national coverage determinations, although specific services are still subject to local coverage determination. 

Coding is particularly important for payment and coverage; if coding does not exist for a given technology, then obtaining coverage can be challenging. Coding is based on current procedural terminology (CPT) codes generated by the American Medical Association CPT panel. It evaluates newer technologies and assigns codes to technologies that are later used for reimbursement. Initial CPT codes are called Category III for research purposes, and allow tracking of technology and workload to assign appropriate revenue value units that later transition to Category I CPT codes used in our daily activities.

Multiple factors influence decisions on whether to cover specific imaging modalities and indications, including discussions at scientific meetings and health policy summits, education of regional health care coverage entities to clarify indications, appropriate use criteria (AUC), individual and population level cost-effectiveness, and iteratively working with professional societies to expand CPT codes for complex applications. To expand coverage of an existing technology, supporting data from trials, guidelines and AUC are needed to justify potential impact and benefit.

The landscape of coverage is constantly shifting. Most people are familiar with the Protecting Access to Medicare Act (PAMA), and the advanced imaging component of PAMA that will require providers to consult AUC from a CMS-approved clinical decision support tool (CDS) when ordering advanced imaging. This requirement is anticipated to shift the burden of reducing inappropriate use from payers to providers. CMS will identify up to 5 percent of ordering providers as outliers, and this subset will be required to obtain preauthorization when ordering advanced imaging for Medicare patients. If ordering providers do not consult CDS, the interpreting providers will not receive Medicare reimbursement. ACC’s SMARTCare project will embed tools along the care pathway to enhance education and decision making and apply AUC to guide appropriate ordering of cardiovascular imaging through the FOCUS decision support tool and registry. 

As another example of evolving coverage and emphasizing that coverage can differ for Medicare and private insurers, Anthem Blue Cross and Blue Shield recently chose to stop covering outpatient cardiac magnetic resonance imaging and computed tomography (CT) scans performed at hospital facilities in nine states (Indiana, Kentucky, Missouri, Wisconsin, Colorado, Georgia, Nevada, New York and Ohio). The intent is to shift utilization to free-standing imaging centers in order to reduce overall cost for both the payer and patient. Costs of studies at free-standing facilities are lower than hospitals because of less overhead and fewer staff. Even though increased use of free-standing facilities may yield cost savings, the trade-off may be adversely increasing fragmentation of care for patients who receive other services at the hospital setting. Coordination and communication of scheduling and results may become more difficult. 

To gain additional insight into some of these challenges, the ACC developed a prior authorization reporting tool (PARTool) hosted on ACC.org. It is invaluable for tracking data on inappropriate cardiovascular testing and denials by insurers to assess for inconsistencies by region and payer. By partaking in this, the data can hopefully yield transformative change to improve the entire authorization process. 

HOW DOES REIMBURSEMENT DIFFER?

Complete reimbursement is not guaranteed despite a study being covered, and depends on local policies, criteria that must be met for each patient and AUC. Many factors weigh into this, including estimates of cost and associated ancillary services. For example, in the case of coronary CT, not only does the cost of CT acquisition need to be considered, but nursing support, physician oversight and possible need for beta-blockade and monitoring also need to be taken into account. 

The Medicare payment framework is complex and differs for inpatient hospital imaging, outpatient hospital imaging and standalone facilities, with separate payment for technical and professional components. In general, Medicare rates serve as the standard to which other payment systems make adjustments.

There are several factors that improve chances of successful reimbursement, including standardized protocoling of acquisition and reporting that meets published guidelines, appropriate disposition of patients, ensuring that insurance-specific items are in reports (including indication and final diagnosis for ICD 10), and recognizing differences in inpatient vs. outpatient coding. Reimbursement is critical because it brings revenue to a practice and covers operating expenses.

To complicate matters, the Medicare Access and CHIP Reauthorization Act (MACRA) may impact imaging reimbursement. Briefly, MACRA replaces the Sustainable Growth Rate formula and is intended to control federal expenditure for health care through changing payments to physicians, moving away from fee-for-service that rewards volume to calculations that emphasize quality and value. Through MACRA, there will be bonuses for clinicians who use AUC through a CDS mechanism in the advancing care in clinical practice improvement category for physicians in the Merit-based Incentive Payment System pathway. This aligns with the PAMA requirement for CDS utilization and underscores the value of guides similar to the ACC FOCUS decision support tool.

Due to challenges that clinicians often face with coverage and reimbursement, the ACC is committed to supporting high-quality cardiac imaging and fair compensation in the evolving health care environment, and the PARtool and FOCUS decision support tool aim to facilitate successful navigation of these complexities.

This article was authored by Richard K. Cheng, MD, MSc, FACC, cardiologist at the University of Washington in Seattle, WA, and Ahmad Slim, MD, FACC, cardiologist at Pulse Heart Institute in Tacoma, WA.