Aetna Prior Authorization Policy Takes Effect, Providers Protest

Updated 7/08/2021: This article has been updated to include a comment from an Aetna spokesperson.

Ophthalmologists are responding in opposition to Aetna’s new prior authorization policy for cataract surgeries.

The American Society of Cataract and Refractive Surgery (ASCRS), the American Academy of Ophthalmology (AAO), and the American Society of Ophthalmic Administrators (ASOA) have issued a joint statement, arguing that imposing a prior authorization on cataract surgeries will delay care for patients and could cause adverse health events.

The organizations stated that the timeline for implementing the changes necessary to prepare for cataract surgery prior authorizations was too brief.

According to Aetna’s May 2021 provider email notice, the payer alerted providers to the policy change and the deadline in its March 2021 newsletter. It also issued a reminder in the May 2021 notice. 

In addition to the timeframe, ophthalmologists shared concerns about the administrative burden that the policy would place on their practices.

“This policy creates an overly burdensome amount of unwarranted work for our teams and unnecessarily restricts access to this essential surgery for patients suffering from sight-threatening cataracts,” said Hayley Boling, COE, member-at-large of the ASOA Board of Directors. 

“This mass application of preauthorization requirements sets a dangerous precedent for other insurance companies and creates a slippery slope for other medical services and specialties.”

Confusion among ophthalmologists regarding the implementation instructions was further cause for concern, the organizations added.

Delays due to the brief timeline, administrative burden, or general confusion could cause dire results for patients’ health, the ophthalmologists argued.

According to the Johns Hopkins Medicine’s Wilmer Eye Institute, cataract surgeries are rarely an emergency. Providers and patients will decide when a surgery is necessary based on the degree to which cataracts impact patients’ everyday lives. 

However, the Wilmer Eye Institute also noted that cataracts are responsible for 42 percent of blindness worldwide. Without treatment, the condition will continue to grow worse and can have deadly implications due to accidental injuries.

“It is difficult to imagine that Aetna would willingly place its reputation and brand at such a high risk knowing there are studies in peer-review journals detailing increased incidents of injurious falls and automobile accidents as a result of delayed surgery,” said Steve Speares, executive director of ASCRS. 

“A prior authorization requirement will delay surgery, will put patients at higher risk, and will alienate patients and physicians.”

According to the press release, potential ramifications of delaying cataract surgery can include increased risks for future cataract surgeries, safety concerns due to dulled vision, permanent blindness particularly for children, and negative impacts on quality of life for patients.

Aetna defended its decision in a statement to HealthPayerIntelligence.

"Since March, we’ve proactively reached out to ophthalmologists in our network, the American Academy of Ophthalmology, and the American Society of Cataract and Refractive Surgery about our new precertification policy on cataract surgery, which is intended to support them in preventing unnecessary surgeries and potential harm to our members," an Aetna spokesperson told HealthPayerIntelligence.

"Based on our decades of experience in reducing unnecessary surgeries, a multi-year, multi-state pilot on reducing unnecessary cataract surgeries, and national clinical guidelines and literature on surgeries, we believe up to 20% of all cataract surgeries may be unnecessary. In our outreach to the Ophthalmology community of clinicians, we explained our rationale and discussed this new policy, including the guidelines used, ensuring them we’d work collaboratively to make sure their patients and our members have timely access to appropriate, necessary care. We value our partnerships with providers as we work together to advance evidence-based practices and reduce unnecessary surgeries for our members and patients."

The payer also offered a brief explanation for its decision in the May 2021 provider email notice.

“In the March newsletter we let you know that cataract surgery procedures need precertification as of July 1, 2021. Placing cataract surgery on the National Precertification List (NPL) lets us review for medical necessity. This helps our members avoid unnecessary surgery,” the notice explained.

Along with cataract surgeries, Aetna announced new pre-authorizations for five other treatments starting on July 1, 2021: ­sacroiliac joint fusion surgery, knee arthroscopy with meniscectomy, vertebral corpectomy procedures, additional lower limb prosthetic codes, and prior authorization for the drug Spinraza® (nusinersen) and for its site of care.

There have been circumstances in which certain care routines around cataract surgeries have been deemed low-value care. Specifically, a study published in 2019 revealed that reducing low-value preoperative services before cataract surgery resulted in lower healthcare spending for health systems.

But when cataracts start to impact everyday life, the surgeries are valuable and very effective: 90 percent of patients who undergo cataract surgeries walk away with better sight, according to the National Institutes of Health’s National Eye Institute website.

Prior authorizations are often a source of contention between payers and providers.

As the nation emerged from the coronavirus pandemic, the American Medical Association surveyed 1,000 providers and found that 94 percent saw delays in care due to prior authorizations. Eight in ten providers added that some patients abandoned treatment while waiting for prior authorizations.

Payers have argued that electronic prior authorizations will reduce the burden and delays in care. After implementing electronic prior authorization solutions, 33 percent of prior authorizations took zero to two hours to complete, according to an AHIP survey.

However, a separate study found that electronic prior authorizations do not alleviate provider burden. The design and interface of electronic prior authorization technologies and the manner of receiving notifications are key components that can either slow down or improve the process for providers.