Organized medicine’s efforts across the nation to torpedo or curb prior authorization recently got a small but encouraging boost when Aetna rescinded its year-old preauthorization requirement for cataract surgeries.
The insurer announced the change in its July monthly notice, dropping required cataract preapproval for everyone except Florida and Georgia patients enrolled in Medicare Advantage. The “pre-certification” requirement initially instituted in July 2021 constituted “a sweeping and unprecedented new policy requiring preapproval for all physician-prescribed cataract surgeries,” according to the American Academy of Ophthalmology (AAO).
“The policy applied equally among its members, from children born with cataracts, to adults whose cataracts interfere with their ability to drive, to people in need of emergency cataract surgery before vision-threatening retinal conditions can be treated,” AAO added in a release following Aetna’s decision to scrap the policy. “The impact was swift and chaotic. The Academy estimates that 10,000 to 20,000 Aetna beneficiaries had their cataract surgery unnecessarily delayed in the month of July [2021] alone. Since then, the Academy has heard countless stories of patients who were delayed or denied sight-restoring care.”
This recent victory is just the latest in medicine’s sweeping fight against insurers’ onerous, care-impeding preapprovals. The Texas Medical Association became a national leader in this fight during the state’s 2021 legislative session, when lawmakers passed a “gold-card” law allowing physicians to earn an exemption from preauthorizations imposed by state-regulated health plans. Under House Bill 3459, physicians can earn that exemption by receiving approvals for at least 90% of prior authorizations for a given medication or service.
Many other states are now expressing strong interest in their own gold-card bills, and in Congress, Rep. Michael Burgess, MD (R-Lewisville), recently coauthored a measure that would bring a gold-card exemption law to Medicare Advantage. (You can quickly write to your representatives to support the measure using TMA’s Grassroots Action Center.)
TMA, along with AAO and the California Medical Association, is also supporting another federal bill targeting prior authorization burdens in Medicare Advantage, the Improving Seniors’ Timely Access to Care Act. That measure, according to AAO, would require plans to:
- Establish an electronic prior authorization program and adopt capabilities for electronic preapprovals, including the ability to provide those coverage decisions in real time;
- Annually publish information on prior authorizations that includes approval percentage and average response times; and
- Ensure qualified medical personnel handle preapproval requests.
Last Updated On
May 15, 2024
Originally Published On
July 20, 2022