Medical Insurance Coverage for ECP Therapy

Medicare Effective July 1, 1999, the Health Care Financing Administration (HCFA) provided coverage for ECP 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.

Please see your cardiologist or local ECP therapy center to discuss details and to determine if you qualify for Medicare coverage.

Private Insurance Private insurance carriers make their own determinations as to what services are covered and the level of reimbursement for covered services. Over 140 insurance carriers pay for ECP therapy on a case-by-case basis, with an increasing number offering coverage on a blanket basis. Please see your insurance carrier to determine their policy regarding ECP therapy.

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 ECP treatment. Reimbursement of ECP treatment by insurance carriers is not uniform. To date, insurance companies have been making case-by-case determinations about reimbursement for ECP treatment. In general, ECP 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 inconsistency 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 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.