Aetna Requires Precertification for All Cataract Surgeries, Angering Ophthalmologists

The health insurance provider said it believes up to 20% of all cataract surgeries may be unnecessary, but ophthalmology groups disagree.

Aetna has launched a new policy that requires prior authorization for all cataract surgeries among its beneficiaries beginning July 1, 2021, frustrating ophthalmologists and surgeons.

The country’s third-largest provider of health insurance and services created the policy to reduce unnecessary expenses associated with cataract surgery, deducing from their own calculations that up to 20% of surgeries are unnecessary, according to a company statement sent to The American Journal of Managed Care® (AJMC®).

The American Academy of Ophthalmology (AAO) and American Society of Cataract and Refractive Surgery (ASCRS) have asked Aetna to immediately withdraw the program, as they believe the policy will only lead to complications for patients seeking cataract surgery. The policy is not being used by any other large medical insurance provider, the groups said.

Prior authorization has been a point of argument for years between physicians across all specialties, as many think it is costly, delays the provision of reasonable care, and negatively affects relationships between physicians and patients. A survey conducted by the American Medical Association found that 94% of doctors have experienced delays in care delivery due to prior authorization, and about 30% have reported that the precertification process has led to a serious adverse event for a patient in their care.

Shutdowns during the COVID-19 pandemic created a backlog of at least 250,000 cataract surgery cases or more, noted David B. Glasser, MD, secretary for Federal Affairs at AAO, in an interview with AJMC®. As more cases get delayed because of the new policy, the number of backlogged surgeries will increase, and result in longer wait times for patients, he said.

The AAO and ASCRS sent a letter to Congress urging them to support the revocation of Aetna’s policy, as well as cosponsor HR 3173, the Improving Seniors’ Timely Access to Care Act. The bipartisan legislation is designed to improve the precertification process among Medicare Advantage Program beneficiaries.

The letter claims that one practice had to cancel cataract surgeries the week of July 12 after spending the weekend on the phone and online with Aetna representatives in a failed attempt to urgently obtain prior authorization approval.

Delays extend the time that patients waiting for cataract surgery may have difficulty performing everyday tasks due to poor visual acuity, increased risks of falls and car accidents, and decreased quality of life, explained Glasser. Also, delays may put those in need of cataract surgery at risk for permanently reduced visual acuity, poorer surgery outcomes, and progressing comorbid retinal disease.

“We feel it’s very unfair to subject 100% of beneficiaries to the program. It’s a problem for patients, but also family and friends because they need to schedule someone to take them to and from the surgery.” he said.

The AAO predicts there will be an increase in case denials given Aetna’s claim that up to 20% of cataract surgeries are unnecessary, which will lead to an increase in case appeals. Appeals typically take 2 weeks but may take longer given the high volume of cases.

In response, Aetna said in the statement emailed to AJMC® that it began working with the groups in March to alert them to the upcoming change. It also referred to previous HHS inspector general reports from 2014 and 2015 examining billing practices for ophthalmology claims.

“We value our partnerships with providers as we work together to advance evidence-based practices and reduce unnecessary surgeries for our members and patients,” Aetna said. “Our data from July shows that more than 99% of cataract precertification cases were compliant with turnaround time standards, which are based on regulatory and accreditation requirements.”

The sight-restoring surgery is the most common procedure performed in all of medicine and has a proven overall success rate of 97% and higher, the ophthalmology groups said. About 4 million Americans choose to have cataract surgery each year, and the number is predicted to increase as the population ages.

“While we share the goal of reducing and eliminating unnecessary surgeries, this is not the way to do it. It’s placing a burden on patients, on practices, on families, and it should be paused, or preferably stopped. We’d be happy to work with Aetna to find another way to address what issue they think is at hand,” Glasser concluded.