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Health Plans | Utilization Management

Cardiovascular

Did you know that unnecessary stress imaging costs $500 million each year in the United States?1  EviCore’s Cardiovascular solution delivers cost savings and improved patient outcomes by ensuring health plan members receive the appropriate test or treatment necessary for their individual cardiovascular-related case presentation or condition.

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Services Covered

Advanced Imaging and Diagnostic Services:

  • Stress testing
    • Myocardial perfusion imaging (SPECT & PET)
    • Stress echocardiography
  • Cardiac CT and MRI
  • Echocardiography:
    • transthoracic (TTE)
    • transesophageal (TEE)
  • Diagnostic heart catheterization
  • Pacemakers
  • Implantable cardioverter defibrillator (ICD)
  • Vascular interventions
  • Percutaneous coronary intervention (post-services only)
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Clinical

EviCore’s evidence-based Cardiovascular guidelines, including our separately maintained pediatric guidelines, are based on the following:

  • Major national and international association and society guidelines
  • Peer-reviewed literature
  • Major treatises
  • Input from health plans and practicing academic and community-based physicians 

In addition, EviCore supports Choosing Wisely. Maintained by the American Board of Internal Medicine (ABIM) Foundation and many national physician organizations, this initiative aims to reduce the overuse of diagnostic tests that are of marginal or no value, or pose risks that are greater than their benefits.

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Network

While EviCore does not contract with cardiovascular groups at this time, imaging centers that provide cardiac testing are contracted within our radiology network. We currently maintain a nationwide advanced imaging network, featuring contracts with providers of imaging services in specific/predetermined locations as well as freestanding facilities.

Frequently Asked Questions

The procedures requiring clinical certification generally include the following:*

  •  Stress testing
    • Myocardial perfusion imaging (SPECT & PET)
    • Stress echocardiography
  • Cardiac CT and MRI
  • Echocardiography 
    • Transthoracic (TTE)
    • Transesophageal (TEE)
  • Diagnostic heart catheterization
  • Pacemakers
  • Implantable cardioverter defibrillator (ICD)
  • Vascular interventions 
  • Percutaneous coronary intervention

*The requirements for clinical certification of specific procedures can vary by health plan. In some instances, covered procedures may be reviewed through a claims-based post-service process.

  • Clinical Review – EviCore uses cutting-edge technology, including our proprietary predictive intelligence and clinical decision support, to assist in the clinical review process. Additionally, our experienced team of nurses and board-certified cardiologists ensures that members receive the most clinically appropriate decisions.
  • Provider Education – We interact with providers during implementation and on an ongoing basis to render support and educational resources, as well as obtain feedback for solution improvements.
  • Analytics and Reporting – We utilize a robust analytics platform that can provide customized reports to meet our client’s data management needs. EviCore’s reporting enhances our data management and analytical architecture to create a present and future solution that serves as the information and analytics platform for the enterprise and its clients.
  • Payment Integrity (Claims Studio): Our proprietary system, Claims Studio, delivers incremental savings through a rigorous focus on accurate claims payment that can be implemented as an extension of the client’s existing claims workflow. With Claims Studio, the claim is pended in the host system and then sent to EviCore, where it is adjudicated with eviCore’s proprietary claims engine, and then returned to the host system for payment – all in the same day.
  • Consumer Engagement (SmartChoice): EviCore’s innovative SmartChoice program serves as a patient outreach service to educate health plan members on available options for the location of their advanced cardiac diagnostic imaging procedure. By presenting lower-cost, convenient, and high-quality options, SmartChoice empowers members to make more informed comparisons and choices.
Cardiology Insights
Clinical Expertise

“As both a patient and cardiologist, I know how life-changing the right cardiovascular care can be. I also know patients are getting low-value care about a third of the time, costing our system over $100 billion. At EviCore, we’re dedicated to preventing waste and improving the patient experience.”

Dr. Sharon Nichols
Executive Medical Director, Cardiovascular

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