In early July, health insurer Aetna began requiring prior authorization for cataract surgeries, a policy change that has many ophthalmologists seeing red.
Under the new policy, ophthalmologists must get the approval of Aetna before performing cataract surgery on any patient covered by the insurer.
A representative for Aetna said the policy is “intended to prevent unnecessary surgeries and potential harm to our members.”
But groups such as the American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology counter that prior authorization causes delays for patients, with physicians often waiting weeks for the authorization to perform cataract surgery. They also said it could create additional expenses because physicians may hire more employees to handle prior authorization requests.
“It’s basically added a layer of inefficiency to the whole practice of medicine,” said Dr. Richard Hoffman, an eye surgeon in Eugene, Oregon, and the president of the ASCRS.
Aetna is the third-largest insurer in the nation and the only one to require prior authorization for cataract surgery. About 4 million people in the United States have the surgery annually.
The AAO and ASCRS claim that 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 claims that unnecessary cataract surgeries may 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 literature on surgeries.”
A spokesperson for the AAO pointed to literature from the 1990s showing that the rate of unnecessary cataract surgery was only about 2%.
Physicians have also complained that Aetna did not inform them enough in advance of the change to allow them to avoid surgery delays.
Dr. Ruth Williams, president of the Wheaton Eye Clinic in Illinois and a former president of the AAO, said she did not learn of the change until late May or June.
“We had to cancel many surgeries for Aetna patients those first few weeks because the prior authorization process takes a while,” Williams said.
She added that the cancellations were a considerable inconvenience for the patients and their family members who had to plan ahead to take time off work for the surgery.
Although insurers once reserved prior authorization for new and expensive tests and treatments, the practice appears to have become more common in recent years. A recent American Medical Association survey found that 94% of physicians said prior authorization had led to a delay in patient care, while 30% said it had led to an adverse event for a patient.
Williams said the Wheaton Eye Clinic now has two employees who handle prior authorization requests full-time.
Prior authorization has also attracted the attention of legislators. In August, the Illinois General Assembly passed the Prior Authorization Reform Act. Signed into law by Democratic Gov. J.B. Pritzker, it reduces the number of healthcare services subject to prior authorization and requires insurers to decide on prior authorization requests within five days.
In Congress, Rep. Suzan DelBene, a Washington Democrat, has introduced the Improving Seniors’ Timely Access to Care Act, which would make changes to prior authorization involving Medicare Advantage plans. The bill has 213 co-sponsors.
