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The Solution is 20/20: Ophthalmologists Ask CMS to Suspend Certain Prior Auth Policies

Analysis  |  By Amanda Norris  
   March 28, 2023

The AAO addresses prior authorization processes that the group says delay care.

In recent comments to CMS, the American Academy of Ophthalmology (AAO) addressed CMS’ proposed rule regarding improving the electronic exchange of healthcare data, particularly in terms of addressing Medicare Advantage prior authorization processes, an area of the rule that the group says has a profound effect on patients.

According to the March 13 letter that the organization shared with HealthLeaders, the AAO says it has been forcefully advocating for ophthalmologists and their patients who have been subjected to sweeping prior authorization policies delaying cataract surgeries, particularly imposed by Medicare Advantage plans.

In the letter, the AAO called for four actions from CMS:

  • Ensuring accountability through enforcement of decision deadlines and public reporting of denial metrics.
  • Avoiding potential administrative burden for provider practices by removing the unnecessary Merit-Based Incentive Payment System Promoting Interoperability measure proposal. 
  • Adding protections for small and rural practices. 
  • Expanding application of the rule’s provision to address other key areas of concern, such as health equity, step therapy, and Digital Imaging and Communications in Medicine standards.

Additionally, the AAO expressed concern that CMS is soliciting comments on the “approach to prior authorization within the Rule that could be applicable under Medicare fee-for-service.”

In a comment sent to HealthLeaders, the AAO noted that while the group supports CMS’ actions trying to simplify prior authorization processes, the AAO is concerned by the solicitation for comments on if and how the approach to prior authorization could be applicable under the Medicare fee-for-service payment model.

“We ardently oppose prior authorization under Medicare fee-for-service and urge CMS to suspend any existing prior authorization policies on services not mandated by legislation. We believe that prior authorization expansion in fee-for-service has the potential to harm Medicare patients’ access to necessary care and should not move forward without a specific legislative mandate,” the AAO said.

Amanda Norris is the Director of Content for HealthLeaders.

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