Cataract Surgery: Humana Prior Authorization Plan Raises Concerns Cataract Surgery: Humana Prior Authorization Plan Raises Concerns

Eye specialists say they are seeking to prevent disruption of patient care from a new Humana Inc policy that delegates review of prior authorization for cataract surgery for its Medicare Advantage patients in Georgia to a contractor, iCare Health Solutions.

In a post on its website for members, the American Academy of Ophthalmology (AAO) said it has scheduled a July meeting with Humana executives “to share clinical concerns and patient disruption experience related to Aetna’s prior authorization policy in an effort to avoid a similar policy in Georgia.”

AAO members were largely successful in their fight against Aetna’s 2021 move to require precertification for cataract surgery. On June 30, the AAO highlighted Aetna’s decision to drop the preapproval step for most cataract surgeries starting July 1. Aetna will still require this for people enrolled in Medicare Advantage in Florida and Georgia.

The AAO said it “remains unclear why these two states are excluded from the rollback.”

Humana’s new cataract surgery policy is meant “to align with Medicare’s approach to determining coverage for these procedures in Georgia,” said Jim Turner, a company spokesman, in an email to Medscape Medical News . Effective August 1, Humana will require prior authorization for its Medicare Advantage customers in Georgia and for cataract surgery or the related YAG capsulotomy process, Turner said. He described iCare Health Solutions as a “company that specializes in performing reviews for medical necessity (and is already doing so in Georgia).”

“iCare will use prevailing Medicare coverage criteria governing cataract surgery and YAG Capsulotomy and follow Medicare timeline guidelines to ensure prompt replies to all requests,” Turner told Medscape Medical News in an email.

Turner also said that Humana and iCare began training and communication about the prior authorization process in April “so that our provider partners and members have the information they need for uninterrupted and timely access to care.”

The AAO has reported that the 2021 implementation of Aetna’s prior authorization policy for cataract surgery was “swift and chaotic.” AAO officials had asked Aetna before the implementation of the new prior authorization step to consider the effect on patients and physicians, David B Glasser, MD, AAO’s secretary for federal affairs, told Medscape Medical News.

“We pleaded with Aetna to go slow,” Glasser said. “Their position was that it had been tested internally and it would work. And of course it didn’t.”

The AAO estimated that, in July 2021 alone, 10,000 to 20,000 people covered by Aetna had their cataract surgery unnecessarily delayed. Will Flanary, MD, an ophthalmologist and comedian who tweets under the name “Dr. Glaucomflecken” (@DGlaucomflecken), posted an April video satirizing the policy. It drew about 13,200 likes and 2500 retweets.

Aetna told Medscape Medical News in a statement that its data from July 2021 shows that more than 99% of cataract precertification cases were compliant with its turnaround time standards, which are based on regulatory and accreditation requirements.

Aetna told Medscape Medical News that its now-abandoned national precertification process was meant to “help reduce unnecessary cataract surgeries, increase the quality of care, and avoid unneeded medical costs.”

“After operating under this policy for one year and accumulating real-time data on these surgeries, we have decided to discontinue our national precertification policy effective July 1, 2022,” Aetna said in a statement. “Going forward, we will focus on retrospective reviews of procedures and providers where questions of medical necessity exist.”

Aetna also said it had begun outreach in March 2021 to ophthalmologists about the recertification policy on cataract surgery, which the insurer said was intended to prevent unnecessary surgeries and potential harm to their members.

“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,” Aetna said in a statement.

Federal records do document cases over the years of unnecessary cataract surgeries.

In 1991, the Office of Inspector General (OIG) of the US Department of Health and Human Services (HHS) reported the results of an examination by an independent medical reviewer of 802 cataract surgeries performed on people enrolled in Medicare. Of these, 1.7% were judged to have been unnecessary. 

A Florida medical group agreed in 2018 to pay the United States $525,000 to resolve allegations that its staff knowingly falsified medical records to bill for cataract surgeries on patients that would not have otherwise qualified for it.

The AAO itself addresses how the decision about surgery can be a judgment call and warns against proceeding in cases where it’s unneeded.

“Typically, no one factor alone can determine whether a particular surgery is needed; instead, individual patient needs must be taken into account. A cataract operation on a 65-year-old man who reports that his vision meets his needs might be unnecessary, whereas a similar cataract in a 55-year-old school bus driver might require surgery,” the AAO says in its advisory opinion on determining the need for a medical or surgical intervention.

Burdensome, Inconsistent

While there may be reasons for insurers to check on medical necessity of any procedures, there’s widespread concern about how the health plans implement these screening steps.

Prior authorization in 2022 can still involve use of faxes and long waits on hold during phone calls. Many lawmakers are pressing to streamline the process though the Improving Seniors’ Timely Access to Care Act of 2021. It has the backing of 306 members of the House of Representatives, which has 435 seats. The Senate version of the bill has the support of 35 members of that 100-member body.

The bill would mandate that Medicare Advantage plans have electronic prior-authorization systems, which could provide real-time decisions in response to requests for routine items and services.

In April, the HHS Inspector General reported on an investigation where it found that 1 3% of prior authorization denials by Medicare Advantage plans were for benefits that should otherwise have been covered under Medicare. The OIG cited use of clinical guidelines not contained in Medicare coverage rules as one reason for the improper denials, as well as managed care plans requesting additional unnecessary documentation.

The nonprofit Kaiser Family Foundation (KFF) in May published an overview of efforts in state and federal governments to compel more transparency about prior authorization rules. California, for example, now requires many plans to use criteria for prior authorization that are consistent with generally accepted standards of care and not substitute their own rules.

Speaking broadly about prior authorization as a concept, Karen Pollitz, KFF’s codirector of the program on patient and consumer protections, said this process can help when medical services are being overused or used inappropriately.

“So it’s not necessarily bad,” Pollitz told Medscape Medical News. “But when it’s used inconsistently, and when it feels like it’s burdensome and actually ends up delaying or blocking access to medically necessary care, that’s when you start hearing the loud complaints.”

Kerry Dooley Young is a freelance journalist based in Miami Beach, Florida. She is the core topic leader on patient safety issues for the Association of Health Care Journalists. Follow her on Twitter at @kdooleyyoung.

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