CMA Blasts Aetna "Pre-certified" Mandate for Cataract Surgeries

California docs say the latest mandate is part of an ongoing and "common practice for health insurance companies to create new obstacles for patients, in hopes of not having to provide essential health care to those who need it."

The California Medical Association is taking Aetna Inc. to task for what the physicians' association claims is cumbersome new red tape requiring prior authorization for cataract surgeries.

The CMA said the latest mandate, effective July 1, is part of an ongoing and "common practice for health insurance companies to create new obstacles for patients, in hopes of not having to provide essential health care to those who need it."

"Aetna claims the practice will 'help members avoid unnecessary surgery,'" CMA said. "The reality is that this bureaucratic roadblock is not some kind of patient protection measure. It is an effort to deny care and pad the insurance company's bottom line."

The CMA noted that Aetna has seen record profits through the COVID-19 pandemic. Acquired by CVS Health in 2018, Aetna's operating income increase from $1 billion in 2019 to $3 billion in 2020.

A recent American Medical Association survey found that nearly 70% of 1,000 practicing physicians surveyed in Dec. 2020 reported that, amid the COVID-19 pandemic, health insurers had either reverted to past prior authorizations policies or never relaxed these policies in the first place.

More than nine in 10 physicians (94%) reported care delays while waiting for health insurers to authorize necessary care, and nearly four in five physicians (79%) said patients abandon treatment due to authorization struggles with health insurers.

In a statement sent to California Health Facts, Aetna said it notified in March the ophthalmologists in their network and related professional associations about the "precertification policy" on cataracts, explained the rationale, and laid down the guidelines.

"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. "Our data from July shows that more than 99% of cataract precertification cases were compliant with turnaround time standards, which are based on regulatory and accreditation requirements."

In California, CMA is sponsoring SB 250 by Senator Richard Pan, MD, which would require state regulators to streamline the prior authorization system to ensure patients have access to critical care. That could include copying legislation in Texas that created an audit-based system where prospective prior authorization is waived for clinicians deemed high-performing.

CMA is also supporting federal legislation—HR 3173, the "Improving Seniors' Timely Access to Care Act" sponsored by U.S. Rep. Ami Bera, MD, D-CA. The bill would standardize and streamline prior authorizations for routinely approved services under Medicare Advantage programs.