A Guide to Insurance Reimbursement

As part of Vasomedical’s commitment to advancing patient access to EECP® therapy, we work directly with the Centers for Medicare and Medicaid Services (CMS), public and private health insurers, and industry stakeholders to ensure appropriate reimbursement for services involving our products.

Patients should contact their primary care physician, cardiologist or local EECP® therapy center to discuss eligibility for treatment and reimbursement coverage.

Current Reimbursement Coverage

Medicare

Medicare is administered by the Centers for Medicare and Medicaid (CMS) and provides coverage for EECP® therapy to Medicare patients who:

  • have been diagnosed with disabling angina (class III or class IV, Canadian Cardiovascular Society Classification or equivalent classification.
  • who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention, such as PTCA or cardiac bypass, because:
    1. Their condition is inoperable, or at high risk of operative complications or post-operative failure;
    2. Their coronary anatomy is not readily amenable to such procedures; or
    3. They have co-morbid states, which create excessive risk.
The Centers for Medicare and Medicaid Services provide additional information on reimbursement. You can search for both national and local coverage decisions on the CMS website, including information on the national coverage decision (NCD) for external counterpulsation.

Private Insurance

Private insurance carriers make their own determinations as to what services are covered and the level of reimbursement for covered services. Currently over 300 third-party payers cover EECP® treatment. Patients should contact their insurance carrier to determine their policy regarding EECP® therapy.

Important: Heart Failure Information


PEECH showed that EECP® therapy improved exercise duration, functional class and quality of life in patients with chronic, mild-to-moderate heart failure who had reduced ventricular function and were already receiving optimal medical therapy. Patients with heart failure of ischemic etiology, i.e. pre-existing coronary artery disease, did better than the overall population. Patients age 65 or older did the best of all.

We believe patients with ischemic heart failure qualify for reimbursement under the current Medicare coverage policy IF they have angina or angina equivalent symptoms, such as dyspnea or fatigue, and they satisfy Medicare’s other listed criteria.

Disclaimer – The information contained herein is provided to assist you in understanding the reimbursement coverage criteria. It is intended to assist providers in accurately obtaining reimbursement for healthcare services. It is not intended to increase or maximize reimbursement by any payer. We strongly suggest you consult your local payer organization with regard to local reimbursement policies.

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The Best Advocates

Patients are the best advocates for obtaining reimbursement and coverage from their health-care insurers.

Patients should ask their doctors and insurance carrier about coverage and reimbursement for EECP® treatment. Reimbursement of EECP® treatment by insurance carriers is not uniform. In general, EECP® treatment is less costly than other angina treatments.

Experience shows that insurers respond more positively to appeals from patients than to appeals from health-care providers. Patients have successfully obtained reimbursement after persistently pursuing this goal. In submitting claims to third-party payers, patients should remember that there is great variability and inc\onsistency in reimbursement practices among insurers regarding any treatment.

Here's a step-by-step guide to the process of obtaining health-insurance coverage and reimbursement:
Step One: Accept Financial Responsibility for Treatment.
It is important to understand the extent and limits of health-insurance coverage entitlements. Patients often assume that health insurance automatically covers all health-care treatments. In reality, patients bear financial responsibility for any costs of treatment that are not covered by their health insurance.
Step Two: Learn About Your Health-care Plan and Specific Coverage for Services.

As a rule, the extent of coverage provided by any insurance plan must be explained in detail in what is known as the "schedule of benefits" and must be provided by the insurance company or employer. This is very important because the schedule also lists items that are not covered or excluded from coverage.

Generally, insurance companies reimburse treatments according to a schedule that is referred to as the "usual, customary and reasonable rate." Others pay a set fee to health-care providers regardless of the actual charge. The exact out-of-pocket expense is affected by any deductible or copayment required when the service is provided.
Step Three: Take an Active Role in the Process of Seeking Reimbursement.
If a health-care insurance company is not able to obtain preauthorization for treatment or initially denies reimbursement, several actions may be taken:
  • Write a Letter of Payment Under Protest
    If preauthorization is denied, it may be beneficial for patients to write a letter indicating that they are paying for treatment under protest and consider the insurers conduct a breach of contract. The letter may state that the patient will pursue reimbursement and expects to receive payment.
  • Write a Letter of Support
    It can be very helpful to write letters requesting insurers to cover necessary treatments. In writing such a letter:
    • State the physician's decision is that the treatment is medically necessary/appropriate.
    • Cite personal experiences of discomfort and limitations caused by your condition.
    • Describe relief provided by treatment.
    • Request that the insurer pay for treatment.
    • Include a letter of medical necessity from the cardiologist, copies of the claim and denial, medical bill, research, and any other relevant correspondence.

    Tips:

    • Direct the appeal to one person who is responsible for handling appeals.
    • Answer any specific reasons the insurance company used to deny the claim.
    • Enclose copies of all relevant correspondence.
    • Keep copies of everything.
    • Write "CLAIM APPEAL" on the letter and on the envelope.
    • Send letter by registered mail, return receipt requested.

  • Use the Grievance and Appeals Process
    Insurance industry officials estimate that 10 percent to 20 percent of health-plan members informally question a coverage decision in any year, while no more than 1 percent file a formal grievance. The handbook provided by the health-insurance carrier should explain the grievance and appeals process. Telephone the carrier for clarification if necessary.

  • Ask the State Insurance Department to Help
    If insurer does not offer a satisfactory response, consider presenting the case to your state insurance department. The insurance industry is regulated by the state insurance department, which is headed by a commissioner. This department is responsible for writing the regulations for the insurance industry.
    • Ask for the section of the department that assists consumers.
    • Ask for an explanation of the grievance process and if there is a standard complaint form.
    • Write to the state insurance department summarizing the dispute and including the name of the insurance company and your policy number.
Do Not Give Up

Do not give up after the first attempt to resolve a problem. Seek help from primary-care physicians, patient liaisons, employers, the medical directors of insurance companies, state insurance department, representative or attorney general, the state board of medicine, and local newspapers. Keep writing and calling.

Disclaimer: Under no circumstances do Vasomedical, Inc., its writers, editors, or publisher accept liability for negative payment determinations or other reliance on information presented herein.