Cardiology Verifications of Insurance Coverage- Key Points

by | Published on Jul 25, 2022 | Insurance Verification and Authorizations

Cardiology Insurance Eligibility Verification
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As physicians focus on addressing their patients’ health concerns, they also need to pay attention to the health of their practice’s revenue cycle. Insurance eligibility verification is the first step in revenue cycle management (RCM). When it comes to cardiology conditions, patients need robust health insurance and cardiology practices need focused, comprehensive insurance verification to confirm patients’ coverage for heart disease.

Heart disease is the leading cause of death in the United States. Cardiovascular disease cause one death every 36 seconds and about 659,000 people in the United States die from heart disease each year. Heart disease cost the nation about $363 billion each year from 2016 to 2017.

These statistics from the Centers for Disease Control and Prevention indicate that the growing volume of heart disease fatalities is a major concern for payers. With the passage of the Affordable Care Act (ACA) in 2010, Americans cannot be denied insurance because of a pre-existing condition – including heart defects. Heart disease is one of the costliest chronic diseases for heathcare payers to cover.

Coverage for Cardiology Services

Cardiology is a discipline where care is provided by multispecialty team that includes a cardiac surgeon, interventional cardiologist, and primary cardiologist working together with advance practice nurses, physician associates, clinical pharmacists, rehabilitation specialists, radiologists, and psychologists. Along with chronic disease management and elective care, a large proportion of cardiology services comprise emergency and urgent care.

Regardless of the type of plan they have, people with heart disease need coverage for Essential Benefits. These services, as listed by WebMD, are:

  • Outpatient services, such as visits to their primary care physician, heart specialists, and lab tests
  • Counseling for diet, smoking cessation, alcohol abuse, or depression to learn how to lower the chance of complications from heart disease
  • Prescription drug coverage
  • Emergency room and hospital coverage
  • Rehabilitation services

Patients have various options for purchasing insurance, but need to choose a plan in which their adult congenital heart disease (ACHD) cardiologist is in network. They should also consider the premium, deductible, out-of-pocket maximum and more. Patients may also require prior authorization for select cardiology procedures.

Understanding insurance billing and coverage can be tricky for cardiologists due to these reasons. Proper insurance verification is crucial to confirm each patient’s coverage and benefits. Performing insurance verifications before the encounter is crucial to ensure they get paid and also to educate patients about their benefits. Partnering with an insurance verification and authorization company with expertise in the field can go a long way in achieving these goals.

What Does Cardiology Insurance Verification Involve?

Patient eligibility and benefits verification is the process by which insurance verification specialists confirm a patient’s coverage, copayments, deductibles, and coinsurance with their insurance company – prior to the office visit. For heart patients, this would also involve checking coverage for cardiology services.

To report demographic and benefits information accurately on insurance claims, cardiology verification specialists will confirm the following details:

  • Eligibility information: Subscriber name, patient name, patient’s relationship to subscriber; patient date of birth; patient gender; patient member number; group name and number; policy effective date; claims mailing address
  • Type of insurance plan: There are various options to obtain coverage for heart defects: through an employer, the Healthcare Marketplace, Medicare or Medicaid, an agent, the insurance company, COBRA (former employer’s insurance), a “high-risk” pool, and a parent’s health insurance plan.
  • Essential Benefits: Regardless of the type of plan, it must cover Essential Benefits. However, large employers are not required to offer the essential health benefits.
  • Plan exclusions
  • Payments: Premium, deductible, out-of-pocket maximum, co-pays or co-insurance.
  • Drug formulary: what medications are included and what tier the patient’s medications are on.
  • Coverage for cardiovascular diagnostic and therapeutic procedures: Leading insurers cover cardiovascular diagnostic and therapeutic procedures when Medicare coverage criteria are met.
  • Coverage for surgery: Whether major surgery is covered and if there is a co-insurance or co-pay involved with surgery and hospitalizations.
  • Network and out-of-network benefits and charges: For adults with congenital heart disease, the insurance policy should allow them to get care from an adult congenital heart doctor. Access to ACHA ACHD Accredited programs must be verified.
  • Referrals and pre-authorizations.
  • Durable medical equipment (DME).

As each state and individual plan has specific rules on cardiology essential benefits and requirements, insurance verification specialists will carefully review the plan’s summary of benefits to understand the specific services the patient has access to and what the costs will be.

Managing Prior Authorizations in Cardiology

Certain cardiology procedures and services require prior authorization. Insurance companies have specific policies for inpatient and outpatient procedure. Cardiology procedures that may require preauthorization can include but are not limited to:

  • Insertion of wireless cardiac stimulator for left ventricular pacing
  • Removal and replacement of wireless cardiac stimulator for left ventricular pacing
  • Quantitative magnetic resonance for analysis of tissue composition
  • Insertion of new or replacement of permanent pacemaker with transvenous electrode(s)
  • Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator
  • Computed tomography, heart
  • Catheter placement in coronary artery(s) for coronary angiography
  • Right/left heart catheterization
  • Echocardiography
  • Myocardial imaging
  • Cardiac magnetic resonance imaging

An insurance authorization and verification company will help cardiologists obtain prior approval from payers when necessary. They will gather information to obtain prior approval, help providers complete the paperwork, and submit prior authorization requests in a timely manner.

They will also help providers submit retrospective authorization requests for services provided in an urgent, emergent or after-hours situation. For e.g., if a stress echocardiogram or echocardiogram is performed on an urgent basis, the services should be performed as determined and documentation must include an explanation as to why the procedure was required on an urgent basis.

If a prior authorization request is not approved, an insurance authorization service provider will help the ordering physician initiate an appeal on behalf of the patient.

Outsource Cardiology Insurance Verification and Authorization – Implement Best Practices

Cardiology is a very challenging field. While advances in medications, wearables, healthcare technology, and novel surgical and catheter-based techniques are helping people better manage their illnesses, cardiovascular disease prevention and treatment are still major concerns. In addition, an Epocrates survey reported that the greatest challenge for cardiologists is uncertainly about government regulations lack of work/life balance, lower reimbursements and increasing costs to practice medicine (

Clearly, cardiologists can benefit by partnering with a medical billing company that provides competent insurance verification and authorization services. Experts are up-to-date with industry regulations and payer rules. Comprehensive support fort eligibility verification and end-to-end support for medical billing and coding can minimize claim denials, increase cash flow, and boost patient satisfaction – all key ingredients for success in medical practice.

Loralee Kapp

Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI.

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