The worst of the COVID pandemic may be past here in the United States, but thanks to Aetna, ophthalmologists still have plenty to deal with this summer. Effective July 1, 2021, the insurer is requiring preauthorizations for all cataract surgeries. Announced on Aetna’s website in March, the policy is intended “to support them [ophthalmologists in Aetna’s network] in preventing unnecessary surgeries and potential harm to our members,” according to a statement the company provided to Ophthalmology Management. It's an essential action, Aetna explains, because its research shows that as many as 20% of cataract surgeries qualify as unnecessary.

Trouble from the get-go

Though the insurer also affirmed its commitment to “work collaboratively [with the eye-care community] to make sure their patients and our members have timely access to appropriate, necessary care,” Aetna’s new requirement has caused stress and confusion in ophthalmic practices for the precertifications necessary for early July surgeries. David Glasser, MD, AAO secretary for federal affairs, says members have already reported significant problems.

“We have heard that some of the approvals go through quickly, but some that [ophthalmologists] feel are clearly indicated have been denied on the website and then require a review,” he says. One member reported spending more than an hour on the phone in a peer-to-peer review trying to get an approval. “Practices schedule cases 2 to 4 weeks ahead, and if they weren’t able to get approvals for their July cases before July 1, those cases had to be rescheduled,” Dr. Glasser explains. And patients must ask the family member or friend transporting them to the surgical center to readjust their own schedules again.

Expect an increase in paperwork

According to Dr. Glasser, Aetna has applied this precertification policy to all its lines of insurance — commercial insurance, HMOs, Medicare Advantage plans. He estimates that Aetna probably has close to a quarter of a million cataract surgeries under their coverage per year. “That’s about 20,000 in the month of July alone, and if people are scheduling 2 weeks ahead, half of that is 10,000 cases,” Dr. Glasser says.

Because cataract surgery is such a common procedure, this means a lot of preauthorizations to obtain, says Steven M. Silverstein, MD, in private practice at Silverstein Eye Centers in Kansas City, Mo. He predicts the new policy may even require practices to hire another full-time employee to deal with all the paperwork precertification will require. “It’s a disservice to both patients and practices,” he says. “It is analogous to requiring precertification from our bank to fill our cars up with gas.”

Recollections vary

The rocky rollout of the new policy might have been avoided had Aetna worked with the ophthalmic community earlier. Though Aetna says it began outreach about the policy change in March, AAO and ASCRS don’t remember it that way. According to Dr. Glasser, the AAO contacted Aetna to request a meeting as soon as the notification of the new policy was posted on the company’s website in March; however, despite multiple attempts, Aetna did not immediately reply, and it was not until June 25 — just one week before the policy was scheduled for implementation — that the ophthalmic societies were able to have a teleconference with the insurer, he says. “Perhaps they thought publishing their notice on their website in March was ‘reaching out,’ but it certainly did not seem so to us.”

And the meeting, he adds, did not provide clarity. Aetna “had published no data about how it [the policy] would work other than, ‘We are going to have this portal, and it will be quick and easy.’ They were not able or willing to share any details about what sort of information would be required or how long it would take to get an approval,” Dr. Glasser says. “They assured us that if there were any issues, just calling the toll-free number and talking to a customer representative would result in an immediate approval if necessary.”

ASCRS concurs on the unsatisfactoriness of the meeting. “Aetna failed to address ASCRS concerns on the operational aspects of the program and offered no relief on the short implementation timeline, its inoperable portal and the unhelpful general support line …,” the society stated in a press release.

Disputed data

The timeline for Aetna’s communication efforts is not the only point of contention. The insurer’s July 9 statement to Ophthalmology Management that “up to 20% of all cataract surgeries may be unnecessary” is viewed with skepticism by the AAO. “That part is stunning to me,” says Dr. Glasser. Previously, Aetna had informed the AAO it had internal data indicating that approximately 46 out of 1,000 cases nationwide were perhaps worthy of review for necessity. “That would be about 4.6%. That would be higher than what most published results suggest, which hovers around 2%, but that is at least in the ballpark.” He acknowledges that the 2% figure comes from data that are a couple of decades old but regards 20% as “inconceivable. It makes me wonder whether [Aetna] know what they are talking about.”

So, what’s this really about?

While the eye-care community shares Aetna’s desire to stop unnecessary surgeries, skepticism about the efficacy of the new policy seems widespread. “If the doctor is lying on the chart, as these [unethical] doctors do, how is a nurse in a pre-cert facility going to know?” asks Larry E. Patterson, MD, in practice in Crossville, Tenn., and OM’s chief medical editor. “You would have to have second opinions; the patients would actually have to see another doctor.”

Moreover, “If we believe Aetna’s 4.6% number or the published literature in the 2% range, for every Aetna beneficiary to have to go through this process to review a potentially suspect 2% to 4.6% really seems very inefficient,” says Dr. Glasser. “I think there’s a substantial financial incentive for Aetna. If they deny cataract surgeries, there will be savings.”

Still, Dr. Glasser anticipates that most of the denials will be overturned on appeal, “because physicians and patients don’t sign up for surgery if they don’t believe they need it.” OM