Eye medical doctors conflict with Aetna over approval for cataract surgical procedure

In early July, well being insurer Aetna started requiring prior authorization for cataract surgical procedures, a coverage change that has many ophthalmologists seeing crimson.

Below the brand new coverage, ophthalmologists should get the approval of Aetna earlier than performing cataract surgical procedure on any affected person coated by the insurer.

A consultant for Aetna stated the coverage is “supposed to stop pointless surgical procedures and potential hurt to our members.”

However teams such because the American Society of Cataract and Refractive Surgical procedure and the American Academy of Ophthalmology counter that prior authorization causes delays for sufferers, with physicians usually ready weeks for the authorization to carry out cataract surgical procedure. In addition they stated it might create extra bills as a result of physicians could rent extra workers to deal with prior authorization requests.

“It is principally added a layer of inefficiency to the entire follow of drugs,” stated Dr. Richard Hoffman, an eye fixed surgeon in Eugene, Oregon, and the president of the ASCRS.

Aetna is the third-largest insurer within the nation and the one one to require prior authorization for cataract surgical procedure. About 4 million folks in the USA have the surgical procedure yearly.

The AAO and ASCRS declare that Aetna’s solely motive for the brand new coverage was that 4-5% of cataract surgical procedures had been pointless. A consultant for Aetna denied that the corporate stated it was solely 4-5%. As a substitute, Aetna claims that pointless cataract surgical procedures could also be as excessive as 20% primarily based on the corporate’s “a long time of expertise in lowering pointless surgical procedures, a multi-year, multi-state pilot [program] on lowering pointless cataract surgical procedures, and nationwide medical tips and literature on surgical procedures.”

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A spokesperson for the AAO pointed to literature from the Nineties displaying that the speed of pointless cataract surgical procedure was solely about 2%.

Physicians have additionally complained that Aetna didn’t inform them sufficient prematurely of the change to permit them to keep away from surgical procedure delays.

Dr. Ruth Williams, president of the Wheaton Eye Clinic in Illinois and a former president of the AAO, stated she didn’t study of the change till late Might or June.

“We needed to cancel many surgical procedures for Aetna sufferers these first few weeks as a result of the prior authorization course of takes some time,” Williams stated.

She added that the cancellations had been a substantial inconvenience for the sufferers and their members of the family who needed to plan forward to take day off work for the surgical procedure.

Though insurers as soon as reserved prior authorization for brand new and costly exams and coverings, the follow seems to have grow to be extra widespread in recent times. A current American Medical Affiliation survey discovered that 94% of physicians stated prior authorization had led to a delay in affected person care, whereas 30% stated it had led to an opposed occasion for a affected person.

Williams stated the Wheaton Eye Clinic now has two workers who deal with prior authorization requests full-time.

Prior authorization has additionally attracted the eye of legislators. In August, the Illinois Normal Meeting handed the Prior Authorization Reform Act. Signed into regulation by Democratic Gov. J.B. Pritzker, it reduces the variety of healthcare providers topic to prior authorization and requires insurers to resolve on prior authorization requests inside 5 days.

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In Congress, Rep. Suzan DelBene, a Washington Democrat, has launched the Bettering Seniors’ Well timed Entry to Care Act, which might make adjustments to prior authorization involving Medicare Benefit plans. The invoice has 213 co-sponsors.

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