Cataract surgery prior authorization an unnecessary burden for practices

April 01, 2022

10 min read


Healio Interviews

Epitropoulos, Howe, Periman and White report no relevant financial disclosures.

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It happened overnight, and all it took was a shift in policy at one insurance company.

On July 1, 2021, Aetna instituted a requirement for prior authorization on all cataract surgeries. Jennifer Howe, a billing and coding specialist at Ophthalmic Surgeons & Consultants of Ohio, said the impact was immediate.

Laura Periman
Introduced in 2021, Aetna’s new prior authorization policy regarding cataract surgery has created barriers and obstacles to treatment for patients, according to Laura M. Periman, MD.

Source: Laura M. Periman, MD

“In June, everything was going smooth,” she said. “On July 1, it was, ‘Follow our demands or you won’t get approved.’”

It was not the first time prior authorization made its way into ophthalmology, but physicians see it as a sign of overreach by an insurance provider.

“When the idea of prior authorizations first came about decades ago, it was reasonable,” Healio/OSN Board Member Laura M. Periman, MD, said. “What has happened is utter mission creep to the point where you can’t even get simple prescription eye medication for your ophthalmology patients. What we see now are egregious plans to create barriers to care. The patients lose, doctors lose, and our staff lose.”

In communications with Aetna last year, ophthalmology organizations such as the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery said they were told the process to obtain approval for cataract surgery could take up to 14 days to complete. However, the hours and days add up for practices and their staff, while patients must put important treatment on hold.

“Our staff has to chase down a truly ridiculous amount of paperwork to clear prior authorization hurdles,” Periman said. “It doesn’t enhance patient care one bit. All it does is create barriers and obstacles to treatment for patients.”

Barriers to care

Last year, the AMA conducted a survey of more than 1,000 physicians to learn more about how prior authorizations affect practices and patients’ lives, as well as how they might affect the employers who select coverage plans that include prior authorizations.

Among patients whose treatment required prior authorizations, 93% of doctors said that the process often or sometimes resulted in delays to necessary care, while 82% reported that it sometimes led to abandonment of care. Additionally, 34% of physicians reported that prior authorization led to a serious adverse event for a patient in their care.

Healio/OSN Board Member Darrell E. White, MD, said that patients who need cataract surgery face an unfair burden when they come up against prior authorization.

“You’ve got patients who are scheduled and have taken time out of their lives,” he said. “They’ve asked friends or family members to take time out of their lives to drive them in. There’s a huge disruption, which can be hours or days in magnitude.”

Darrell E. White, MD
Darrell E. White

White said patients who experience delays or potential cancellations may have significant compromises to their vision. While the standard for the prior authorization is 20/50 vision, White said there is much more to vision that needs to be considered.

“Vision is more than what you see on the chart,” he said. “That shows maximum contrast — it’s the blackest black against the whitest white. Under those circumstances, patients are seeing the very best they can possibly see. However, there are other folks who can see 20/40 or even 20/30 on a Snellen vision chart, and yet, at night, they see maybe 20/60, 70, 80, 100. They’re not functional at night.”

Forcing patients to wait or denying their surgery affects many parts of their lives, from driving to watching TV to even just being able to see inside their house at night, White said.

The issue is confounding for cataract surgeons simply because they see the procedure as safe and beneficial for their patients.

“This isn’t a super expensive surgery,” Periman said. “It’s very efficient. It’s very low cost on a relative scale. It helps restore quality of life, as well as visual performance, which translates into safety.”

According to a survey conducted by AHIP in 2019, the primary goals of prior authorization programs are to improve quality and promote evidence-based care, as well as to reduce unnecessary spending and address areas prone to misuse. The survey also found that the most common reason for denial of an initial prior authorization request was that the provider did not submit the necessary clinical information.

Healio/OSN Board Member Alice T. Epitropoulos, MD, FACS, said that the Aetna policy has been a hot topic among her colleagues.

“One of my colleagues has spent 20-plus hours trying to secure coverage,” she said. “This particular patient is in her 60s with plenty of life to live, and for Aetna to deny all appeals and wait for her vision to get worse before covering her surgery is really irresponsible. It ignores the standard of care.”

Alice T. Epitropoulos, MD, FACS
Alice T. Epitropoulos

She said the policy ignores any potential safety issues patients may face if they have to wait for their vision to get worse.

“Patients with visually significant cataracts are at 2.5 times higher risk for getting in motor vehicle accidents,” she said. “They are at high risk for missing a step or curb and falling. This policy ignores nationally recognized clinical guidelines on cataract care and endangers our patients’ health and safety.”

According to a study published in JAMA Internal Medicine in 2021, patients who underwent cataract surgery had 30% lower risk for developing dementia compared with patients who did not undergo surgery. White said this study shows how wide of an impact cataract surgery can have on a patient’s quality of life.

“We see a direct link between vision and one of the scourges of health in the older population,” he said. “How do we fix it? We fix it with one of the most successful surgical procedures in the United States and perhaps the safest procedure in the history of medicine.

“You’ve got people who have a visually significant but fixable problem who are being told that their care needs to be delayed and in some cases canceled. It’s being denied despite standard of care being applied in making the decision to take the cataracts out. You have nonmedical people making an adjudication for the procedure. Often, it’s non-ophthalmologists or people who aren’t eye surgeons making the decision.”

In their initial statement regarding the policy, AAO and ASCRS estimated that 10,000 to 20,000 patients would have their surgeries delayed in the first month.

Epitropoulos said delays can have other consequences, particularly among patients who are also experiencing issues related to glaucoma. Cataracts and glaucoma are two of the most common diseases in the U.S. and frequently coexist, she said.

“When you develop vision loss from glaucoma, it is irreversible. For that reason, treatment should not be delayed,” she said. “Both of these eye conditions can be treated at the same time to give a patient the best chance for a good outcome. It’s just another reason that this Aetna policy is unacceptable.”

Practice impact

According to the AMA physician survey on prior authorization, practices complete 41 prior authorizations per physician per week on average, while physicians and their staff reported spending an average of 13 hours each week on completing prior authorizations.

White said the staff in his practice spends about 40 hours per week on pharmaceutical prior authorizations.

“That doesn’t even include the time we spend on surgical prior authorizations,” he said.

Before July 2021, Howe said cataract surgery was one of the easier procedures to process. Now, it is taking up most of her time.

“I have to send over triple the amount of the same information every day,” she said. “We have to fill out a questionnaire online and then another questionnaire on paper. We’re sending clinicals two or three times a day through fax and email. Then, it’s up to them how much longer they want to take.”

Howe said the whole process takes 7 to 10 days. If the authorization is denied, it could be another 2 weeks of handling the appeal process. There have been times when she has spent 20 to 30 hours coordinating prior authorization for a single patient. Even when the process moves swiftly, Howe said she finds that she is still spending most of her time doing prior authorizations for cataract surgery.

“Most of my week is consumed,” she said. “Doing prior authorizations is not my whole job, but Aetna has really slowed down what I get to do in the office since July.”

The workload that practices have to take on due to prior authorization requirements has become particularly difficult in an era of staffing shortages. Periman said employees are already under significant strain.

“There are more jobs available than there are people to work them at this point. It can be difficult to find someone who is interested in doing prior authorizations,” she said. “That’s a job that takes a lot of resilience to deal with brick walls all day long. At the end of the day, it has its intended effect, which is decreasing access for patients.”

White said every health care professional, either physician or staff, has to deal with burdens such as electronic health records and pressures added by the ongoing pandemic. Onerous regulatory burdens only add to that stress.

“We’ve got a health care workforce that’s stretched to the max,” he said. “We are now spending on average at least 2 hours on successful Aetna prior authorizations. Most doctors are not involved until a peer-to-peer discussion. Before that, it’s a burden that’s being borne by the staff, patients and their family.”

Epitropoulos said the administrative issues related to prior authorization have become overwhelming, affecting every practice large and small.

“It’s created additional costs and, in some cases, forced practices to hire additional staff just to handle the prior authorization process,” she said. “With current staffing shortage issues, that can be very challenging.”

Howe, who works in a practice with Epitropoulos and eight other physicians, said a staff member exclusively works on prior authorizations, but it has been difficult to retain people in the position.

“Since the beginning of this Aetna policy, I told Dr. Epitropoulos that I would handle them,” she said. “I do her billing anyway, and it would be easier than trying to train somebody else on what they have to do. It’s just easier that way.”

For most practices, hiring a staff member whose sole responsibility is prior authorizations is not a luxury they can afford, White said.

“Where is that money coming from?” he said. “We can’t cover the hiring of an employee to do this uncompensated service that we’re providing for patients. This is not a problem that needs to be solved at the medical provider level. This is an external problem that’s being dumped on us. This is an assault on patients, doctors and the staff who work for us.”

Periman said all physicians might not have the same understanding of how burdensome prior authorizations are for their staff. They might delegate the responsibility and not see how much work goes into it.

“I challenge every doctor to handle a prior authorization themselves,” she said. “Write the prescription, log into the program, take the call from the health insurance company. That could give them a better understanding of the process because they’re a little bit protected from it. They need to know just how bad it is.”

Next steps

Periman said it is clear that something needs to change when it comes to prior authorizations, and she encourages her colleagues and patients to speak against them. She often urges her patients to write to their representatives and even to talk to their employers about making a change to their insurance plan if they include overreaching prior authorizations.

In its physician survey, the AMA said that delays related to prior authorizations could hurt a patient’s work productivity. More than half of physicians reported that a prior authorization interfered with a patient’s ability to perform his or her job responsibilities.

For Periman, one of the most effective means of fighting back against prior authorizations has been social media. She uses her Twitter account to call out companies publicly if the delays start to get particularly bad.

“I had one patient who had to wait through three or four rounds of authorization for a medication that they desperately needed,” she said. “Finally, I tweeted at the company and called out their greed. They called my office the next day, and the medication was finally approved.”

White said it is unlikely that any change will come simply from lobbying. However, he said it is important to fight back against what he called misinformation from insurers.

“The deceptive underpinning of what Aetna is doing is that the amount of fraud happening in cataract surgery is a rounding error,” he said. “Of course, there is no such thing as a ‘no fraud’ circumstance when government or insurance money is involved, but the fraud from a financial standpoint is trivial.”

He added that he finds claims that prior authorization prevents complications from unnecessary surgeries confusing simply because cataract surgery is so safe.

“It’s perhaps the safest surgery done in the U.S.,” he said. “Does that mean that people have license to do unnecessary surgery? Of course not. There’s really only one reason why a company does this — to hold onto money as long as possible.”

On the legislative front, Epitropoulos said a bill currently working its way through congress — H.R. 3173, Improving Seniors’ Timely Access to Care Act of 2021 — is aimed at reducing prior authorization-related delays to care.

“This act would put guardrails around the use of prior authorization under Medicare Advantage plans,” she said. “More importantly, it would help streamline the approval process so that patient care is not unnecessarily disrupted or denied.”

Similar limitations on prior authorization have also passed or are currently working their way through state legislatures, Epitropoulos said, adding that seeing more elected officials getting involved is reassuring.

“I don’t think we should give up on this,” she said. “It’s affecting our patient care, and in the long run, patients are the ones that are ultimately impacted. We have to be advocates for our patients and their care.”

Click here to read the Point/Counter to this Cover Story.

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