Aetna drops prior authorization for many cataract surgical procedures

Aetna will not require prior authorization for many sufferers in search of cataract surgical procedure.

The insurer reversed the year-old coverage for its 24.5 million members besides Medicare Benefit enrollees in Georgia and Florida. The change took impact Friday, and got here after the insurer reviewed a yr’s price of information on the surgical procedures, an Aetna spokesperson wrote in an e mail.

The coverage reversal comes as federal consideration to improper use of prior authorization amongst Medicare Benefit carriers grows.

“We repeatedly consider and replace our scientific insurance policies and processes to assist guarantee our members are supplied with the very best care,” the spokesperson stated. “This determination helps that follow.”

Aetna, owned by CVS Well being, didn’t reply to interview requests about why Medicare Benefit policyholders within the two states should nonetheless request prior authorizations for the surgical procedure.

Annually, 2 million cataract operations are carried out nationally at a price of $6.8 billion. Half of all Individuals can have cataract surgical procedure by age 80, and 30 million can have it within the subsequent 10 years, in accordance with the Facilities for Illness Management and Prevention. Conventional Medicare or Medicare Benefit carriers usually cowl not less than 80% of prices related to the surgical procedure.

Final July, Aetna unveiled the prior authorization requirement to cut back the speed of pointless procedures, enhance care high quality and scale back healthcare prices, the corporate spokesperson stated.

Cataract surgical procedure is without doubt one of the most typical in-office procedures within the U.S., and gives the fewest issues and highest affected person satisfaction, stated Dr. David Glasser, secretary for federal affairs on the American Academy of Opthalmology.

He pointed to a 2013 evaluation of greater than 368,200 sufferers that discovered the process improved sight for 94.3% of people with 20/40 imaginative and prescient and 61.3% of sufferers with 20/20 imaginative and prescient. Fewer than 2% of sufferers surveyed reported worse imaginative and prescient after the operation, in accordance with the examine printed within the Journal of Cataract and Refractive Surgical procedure.

Earlier than the insurer unveiled the requirement final July, Aetna officers cited inside knowledge that confirmed the portion of its members receiving pointless cataract surgical procedures was a lot larger than the academy’s estimate of three% of cataract operations carried out annually, Glasser stated.

“They thought they might see a major discount within the variety of surgical procedures carried out and I believe that they didn’t,” Glasser stated.

After Aetna the carried out the coverage final July, he stated the academy notified the insurer about doctor complaints that its digital prior authorization system processed requests too slowly and inaccurately, resulting in delays in affected person care.

“We applaud Aetna for stopping it in most of their strains of enterprise throughout many of the nation, and we sit up for working with them to see what’s it that they realized,” Glasser stated. “From the very starting, we thought they might discover a very low denial price, and that may be not solely burdensome for practices and sufferers, but in addition burdensome for them.”

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