American College of Cardiology

(MARCH 1999) As insurance companies become larger through mergers and acquisitions, working with the local or regional medical directors who make decisions on medical policy is increasingly crucial to practicing cardiovascular specialists. During periods of transition, such as the first six to 18 months after a large merger of insurance companies, there are opportunities to initiate collaborative review of existing coverage policies.

Medical directors are typically responsible for setting coverage policy and making determinations of medical necessity. They respond to internal company targets for accuracy in claims processing as well as to external information regarding care, cost, and outcomes. Medical directors of Medicare carriers are required to have a carrier advisory committee (CAC) to support medical policy decisions for the state. Although the CAC mechanism is used differently by each medical director, the group is required to include at least one cardiovascular specialist. Medical directors for medical decision making exist for all insurance companies, although they usually have a more informal advisory network of practicing physicians.

Approach for New Procedures and Treatments
To obtain appropriate coverage for new cardiac magnetic resonance imaging procedures, we have presented the medical directors in our state with an evidence-based approach. A crucial hurdle is to persuade local payers that services are not experimental and have received Food and Drug Administration approval. It is also useful to obtain a new or revised CPT code describing the service, which will lead to the assignment of relative values units to the code and so define the level of Medicare reimbursement. Both of these steps take place under the auspices of the American Medical Association, but the American College of Cardiology can be very helpful in shepherding requests through the system.

It is important to present to the medical director solid published data and demonstration of respected professional opinion. Not surprisingly, the financial assessment of how this procedure compares to the relevant alternatives can prove to be the most persuasive component.

Our approach is both personal and formal. We first sought out the most significant local payers and most friendly medical directors. There is more to be gained by a collaborative than an adversarial approach to prove that the service would ultimately better serve their patients, provide differential diagnostic information, and ultimately save money. It is important not to overcharge or oversell, as these strategies will undermine the credibility of the case. Written policies of other Medicare carriers and payers as well as American College of Cardiology guidelines and competence statements can augment arguments here.

There is no downside to building working relationships with medical directors. All payers, including those for Medicare, are scrutinizing their expenditures and aggressively looking for ways to control costs. All specialists, particularly cardiovascular specialists, would do well to acquire the skills of working with their local medical directors.

For further information about current changes in the local medical policies that may be affecting your practice, contact your chapter of the College. Additional questions can also be addressed by contacting Heart House, Practice Organization and Management, at 800-435-9203 or at pom@acc.org.

Samuel Wickline, MD, is professor of Medicine, adjunct professor of Physics and Biomedical Engineering, and co-director of the Cardiovascular Division at Barnes-Jewish Hospital at Washington University Medical Center, St. Louis; and Christine Lorenz, PhD, is assistant professor of Medicine and Biomechanics and director of the Center for Cardiovascular MR, Barnes-Jewish Hospital at Washington University Medical Center, St. Louis.

Copyright © 1999 American College of Cardiology