And nowhere are they changing faster than in Cardiac CT. The latest agent of that change is a sudden shift in the insurance reimbursement landscape.
The introduction of 64-Slice Coronary CT Angiography promised to revolutionize, and possibly threaten, the practice of cardiology. But the difficult reimbursement environment quelled the initial burst of enthusiasm and limited widespread use. Early adopters found they encountered unexpected expenses and patients who preferred an invasive procedure covered by their insurance to paying out of pocket for a simpler and safer test.
The need for cardiologists to be prepared for wider use of cardiac imaging has been a settled issue for several years. When the ACCF/AHA Cardiac CT Credentialing Guidelines were published many cardiologists quickly signed up for CT training to ensure they qualified for Level II Training prior to the grandfathering deadline of mid-2008. When the deadline was extended to 2010 it seemed to remove the sense of urgency and many put off their training.
Most of the cardiology community is unaware of the recent and sudden changes in insurance reimbursement. In just the past few weeks a quiet revolution occurred which could make the delay in training look very short-sighted in retrospect.
While Medicare’s local carriers have released coverage guidelines for Cardiac CTA in all 50 states, the private carriers, with a few exceptions such as United Healthcare, have generally continued to deny coverage for Cardiac CTA. This past month Aetna revised its coverage guidelines for Cardiac CTA and now offers reimbursement for Cardiac CTA, using the category III “T” codes, for a broad range of indications. Cigna announced it's coverage guidelines for CTA in August. Third party pre-authorization companies, such as CareCore and NIA, have revised their clinical guidelines, too. These companies will now approve Cardiac CTA under many circumstances. Blue Cross carriers in several states have also implemented new guidelines and will cover Cardiac CTA.
With these changes Cardiac CT Angiography may now be covered for the majority of eligible patients in many states. And the reimbursement rates are generally very good.
What does this mean for cardiology?
The implications are difficult to assess and will depend to a large degree on how rapidly the cardiology community can respond to the challenges this creates.
On the upside, the availability of reimbursement for a very substantial segment of the insured population means that Cardiac CTA should now be a profitable venture for cardiologists.
The potential downside is that Cardiac CTA is also now a profitable venture for radiologists. And the radiologists have a very big head start. Many of them already have the equipment and experience in place. Adding Cardiac CTA for a radiologist requires little more than some minor changes in their marketing efforts.
Cardiologists should not under-estimate the potential impact Cardiac CT will have on their referral patterns. Our experience has been that when radiologists offer Cardiac CTA to primary care physicians, many of the patients that previously were sent to cardiology end up in their scanners instead. We have seen some local radiology centers getting as many as 20 referrals per day from area primary care physicians. Many of these end up never seeing a cardiologist because the radiologist has already ruled out coronary disease.
Many cardiologists have thought that getting Level II Training could wait until closer to the mid-2010 deadline. Now that there is a financial incentive for hospitals and radiologists to move more aggressively into cardiac imaging, the ACCF/AHA grandfathering deadline is no longer the defining factor. In addition to the other competitive disadvantages that cardiology is suddenly faced with, many of the insurance companies and pre-authorization companies have published minimum training criteria requirements for authorizing or reimbursing Cardiac CTA. Whether you own a CT Scanner or try to partner with a hospital to read your own scans it may not be possible for cardiologists to take advantage of the new reimbursement environment without Level II Training Credentials.
Regardless of the ACCF/AHA timetable and the introduction of the Cardiac CTA Board Exam in 2008, it is clear that if the cardiology community does not want to see a dramatic shift of their patients to radiologists the time to get high quality, Level II Training is now!
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