Bringing Payors On Board: Reimbursement Strategies for Coronary CT Angiography

By: 
Jeffrey J. Fine and Timothy W. Attebery

 

March 23, 2007

Coronary computed tomography angiography (CCTA) has recently made significant technological and clinical advances. Submillimeter slice thickness, increased detectors and reduced acquisition times have multiplied the number of patients that can benefit from noninvasive diagnostic imaging. CCTA presents a cost effective opportunity for early cardiovascular disease detection among this large cohort of symptomatic moderate risk patients.

Unfortunately, and despite the clinical and economic promise of CCTA, many private payors are not currently reimbursing for this service or reimburse inadequately due to outdated and limited data or a lack of education regarding CCTA.

Cardiovascular Innovations, LLC (CVI) has developed a comprehensive methodology to approach payor negotiations for CCTA. CVI has conducted successful meetings with payors in nine states and using our reimbursement prospectus, combined with the clinical and economic data of the CCTA Data Registry, has secured either policy change or pilot reimbursement in each location.

The vast majority of payors will concede that CCTA reimbursement is forthcoming. The principal concern seems to be losing control after reimbursement is initiated. Using that concern can be to the CCTA operator's advantage when initiating payor negotiations. By providing standards and reporting mechanisms that allow the payor to “stay in front of” the technology, this fear can be suppressed.

Payors’ Primary Concerns

Beyond the anxiety of “opening the floodgates,” the payors have expressed two major concerns. First, there is the belief that CCTA will become a “layered test.” If the practitioner orders a nuclear perfusion study followed by a CCTA and then a diagnostic catheter angiography, we have simply layered another diagnostic test, thereby increasing costs. However, if CCTA is substituted for the nuclear perfusion study or catheterization, a cost savings has occurred, as CCTA is the least expensive of the three diagnostic tests. The CCTA Data Registry, with over 20,000 cases, supports that layered testing is occurring in less than one percent of cases. More often, CCTA is being used as an alternate test with a realized savings to the healthcare system.

The second concern among payors is that CCTA will be utilized as a “screening test”. Again, the CCTA Data Registry evaluates the clinical indications used to order CCTA studies across the country. These data support that CCTA studies are being ordered extremely judiciously in accordance with the published clinical appropriateness criteria, thereby preventing CCTA from being used for patient screening.

When engaging the payors for CCTA reimbursement, these issues must be systematically addressed. A comprehensive reimbursement prospectus comprised of robust clinical and economic data, strict ordering, interpretation and equipment standards, recent peer reviewed research and solid pilot program framework will dispel these misconceptions and pave the way through reimbursement discussions.

Enhanced success has been realized when presenting data registry participation for CCTA operators. The CCTA Data Registry, with quarterly reporting and benchmarking, offers a “safety net” to the payors and monitors the clinical and economic benefits of CCTA. Data monitoring allows the payor to evaluate and control the technology.

Waiting for a national CCTA reimbursement policy may, at times, appear the path of least resistance. However, taking a proactive approach and engaging your local and regional payors will benefit your patients and may allow CCTA reimbursement during that uncertain period while awaiting a national coverage policy. <