June 17, 2024

Aetna will no longer require prior authorization for most patients seeking cataract surgery.

The insurer reversed the year-old policy for its 24.5 million members except Medicare Advantage enrollees in Georgia and Florida. The change took effect Friday, and came after the insurer reviewed a year’s worth of data on the surgeries, an Aetna spokesperson wrote in an email.

The policy reversal comes as federal attention to improper use of prior authorization among Medicare Advantage carriers grows.

“We regularly evaluate and update our clinical policies and processes to help ensure our members are provided with the best care,” the spokesperson said. “This decision supports that practice.”

Aetna, owned by CVS Health, did not respond to interview requests about why Medicare Advantage policyholders in the two states must still request prior authorizations for the surgery.

Each year, 2 million cataract operations are performed nationally at a cost of $6.8 billion. Half of all Americans will have cataract surgery by age 80, and 30 million will have it in the next 10 years, according to the Centers for Disease Control and Prevention. Traditional Medicare or Medicare Advantage carriers typically cover at least 80% of costs associated with the surgery.

Last July, Aetna unveiled the prior authorization requirement to reduce the rate of unnecessary procedures, increase care quality and reduce healthcare costs, the company spokesperson said.

Cataract surgery is one of the most common in-office procedures in the U.S., and offers the fewest complications and highest patient satisfaction, said Dr. David Glasser, secretary for federal affairs at the American Academy of Opthalmology.

He pointed to a 2013 analysis of more than 368,200 patients that found the procedure improved sight for 94.3% of individuals with 20/40 vision and 61.3% of patients with 20/20 vision. Fewer than 2% of patients surveyed reported worse vision after the operation, according to the study published in the Journal of Cataract and Refractive Surgery.

Before the insurer unveiled the requirement last July, Aetna officials cited internal data that showed the portion of its members receiving unnecessary cataract surgeries was much higher than the academy’s estimate of 3% of cataract operations performed each year, Glasser said.

“They thought they would see a significant reduction in the number of surgeries performed and I suspect that they did not,” Glasser said.

After Aetna the implemented the policy last July, he said the academy notified the insurer about physician complaints that its electronic prior authorization system processed requests too slowly and inaccurately, leading to delays in patient care.

“We applaud Aetna for stopping it in most of their lines of business across most of the country, and we look forward to working with them to see what is it that they learned,” Glasser said. “From the very beginning, we thought they would find a very low denial rate, and that might be not only burdensome for practices and patients, but also burdensome for them.”

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