Ophthalmologists fight over Aetna’s approval for cataract surgery


In early July, health insurer Aetna began requiring prior authorization for cataract surgeries, a policy change that makes many ophthalmologists see red.

Under the new policy, ophthalmologists must obtain Aetna’s approval before performing cataract surgery on any patient covered by the insurer.

A representative from Aetna said the policy is “intended to prevent unnecessary surgeries and potential harm to our limbs.”

But groups such as the American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology counter that pre-authorization causes delays for patients, with doctors often waiting weeks for authorization to perform eye surgery. cataract. They also said it could result in additional expense, as doctors could hire more staff to process pre-authorization requests.

“It has essentially added a layer of inefficiency to the whole practice of medicine,” said Dr. Richard Hoffman, eye surgeon in Eugene, Ore., And president of ASCRS.

Aetna is the third largest insurer in the country and the only one to require prior authorization for cataract surgery. About 4 million people in the United States have the surgery each year.

The AAO and ASCRS say Aetna’s only reason for the new policy was that 4-5% of cataract surgeries were unnecessary. A representative for Aetna denied that the company said it was only 4-5%. Instead, Aetna says unnecessary cataract surgeries can be as high as 20% based on the company’s “decades of experience in reducing unnecessary surgeries, a multi-year, multi-state pilot. [program] on reducing unnecessary cataract surgeries; and national clinical guidelines and the surgical literature. “

An AAO spokesperson pointed out Literature 1990s showing that the rate of unnecessary cataract surgery was only around 2%.

Doctors also complained that Aetna had not informed them well in advance of the change to allow them to avoid surgery delays.

Dr Ruth Williams, president of the Wheaton Eye Clinic in Illinois and past president of the AAO, said she didn’t learn of the change until late May or June.

“We had to cancel a lot of surgeries for Aetna’s patients in the first few weeks because the pre-authorization process takes a while,” Williams said.

She added that the cancellations were a huge inconvenience for patients and their families who had to plan ahead to take time off work for the surgery.

Although insurers once reserved pre-authorization for expensive new tests and treatments, the practice seems to have become more common in recent years. A recent American medical association investigation found that 94% of physicians said prior authorization resulted in a delay in patient care, while 30% said it resulted in an adverse event for a patient.

Williams said the Wheaton Eye Clinic now has two employees who process pre-clearance requests full-time.

Prior authorization has also caught the attention of lawmakers. In August, the Illinois General Assembly passed the Prior Authorization Reform Act. Promulgated by Democratic Governor JB Pritzker, it reduces the number of health services subject to prior authorization and obliges insurers to vote on requests for prior authorization within five days.

In Congress, Representative Suzan DelBene, a Democrat from Washington, introduced the Improving Elderly Access to Health Care Act, which would change the prior authorization of Medicare Advantage plans. The bill has 213 co-sponsors.

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Key words: Health care, Etna, Insurance sector, health insurance, Laser eye surgery, Assurance, Advantage of Medicare, Illinois

Original author: David Hogberg

Original location: Ophthalmologists fight over Aetna’s approval for cataract surgery


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