Cataract surgeries subject to requirements for prior approval for some in Georgia – but not in other states

Georgians who are members of two large Medicare Advantage plans may face a tougher time getting cataract surgery – a routine eye procedure for older people. That’s because Aetna and Humana now require doctors in Georgia to get prior approval for cataract removal for Medicare Advantage enrollees. Georgia eye doctors say the requirements are burdensome and don’t apply in most other states.

The problem began last year when Aetna started requiring prior authorizations for cataract surgeries in its Medicare Advantage plans across the country.

This summer Aetna rolled back the policy – except in Georgia and Florida.

Six weeks ago, Humana, another large Medicare Advantage insurer, enacted a similar policy requiring prior authorizations for cataract surgeries in Georgia.

Georgia eye doctors say Aetna and Humana’s new requirements force them to engage in lengthy back-and-forths over billing for what should be routine.

“It’s a burden and a delay,” said Dr. J. Chandler Berg, an Albany-area doctor and president of the Georgia Society of Ophthalmology.

Berg said his practice tries to schedule cataract surgeries for certain Medicare Advantage patients a month – instead of one week – in advance to allow extra time for the prior approval process.

“It’s a lot more work,” Berg said. “It’s a delay on the patient.”

Sometimes insurers require patients to get glasses with anti-reflective coating before they can get cataract surgery. Berg finds that policy a waste of time and money because glasses cannot fix cataract glare.

Dr. Ninita Brown of Atlanta's Thomas Eye Group said the new policy has added work for her already stretched-thin staff and distressed her patients.

Brown said she understands why some new or rare treatments need prior approval but doesn’t think the requirements should apply for something as common as cataract removal.

“It kind of surprised me that someone would look at this as something that is some type of extra benefit of health care, which really should be the standard of care,” she said. “It's … an unnecessary burden on these old folks that are struggling already with their vision.” Cataracts cloud vision and make people more susceptible to falls and auto accidents. They can even contribute to increased dementia risk, according to a recent study. Most adults will need the procedure at some point, ophthalmologists say, and it’s highly effective and safe. The procedure is one of the most common surgeries in the United States and can be performed at an outpatient surgery center or at a hospital, according to the National Eye Institute.

More than half of Georgians enrolled in Medicare, the federal insurance program for adults 65 and older, are members of private Medicare Advantage plans rather than the traditional Medicare program for their health insurance, according to the Kaiser Family Foundation.

Older Americans can enroll in Medicare Advantage plans through private health insurance companies instead of obtaining health care through traditional Medicare.

Medicare Advantage plans have seen rapid growth nationwide over the past five years. Humana has about 257,000 members in Georgia, the company said. Federal data indicate Aetna has about 133,000 Medicare Advantage members in Georgia, although the company would not confirm the number. Humana and Aetna said their different Medicare Advantage policy in Georgia is due to a preexisting relationship with Florida-based iCare Health Solutions, a contractor that handles eye-care claims “The reason for this change is to better align with Medicare’s approach to determining coverage for these procedures in Georgia,” Humana spokesman Jim Turner said. “iCare … is using prevailing Medicare coverage criteria ….and follows Medicare timeline guidelines to ensure prompt replies to all requests.” Aetna analyzed “realtime data” about cataract surgeries for a year and, based on its findings, decided to discontinue the prior authorization policy earlier this year, said Kimberly Eafano, a spokesperson for the company, which is owned by CVS. But the situation in Georgia and Florida is different, she said. “Aetna has been engaged in a 10-year relationship with iCare Health Solutions to manage ophthalmology and optometry services in Florida,” Eafano said. “Almost two years ago, Aetna expanded this arrangement to include the state of Georgia, where iCare also has a community presence.” Officials from iCare did not respond to multiple emails and phone calls requesting comment.

A spokesperson for the federal regulator of Advantage plans – the Centers for Medicare & Medicaid Services (CMS) – said Medicare Advantage contractors are allowed to make their own decisions about covering services but, in general, Advantage plans have to follow traditional Medicare’s coverage guidelines.

“Medicare Advantage plans may apply internal coverage policies, including additional coverage requirements to better define the need for the service, that are no more restrictive than traditional Medicare’s national and local coverage policies,” he said. “For services that are not subject to existing local and national coverage requirements, Medicare Advantage plans may apply third-party guidelines, such as guidelines used by contractors engaged by the Medicare Advantage plan to make coverage determinations.”

Spokespersons for the Georgia Attorney General and the state Department of Insurance both said their agencies forward complaints about Medicare Advantage plans in Georgia to CMS. Prior authorization requirements are a national concern. A report the Office of Inspector General in the U.S. Department of Health and Human Services released last April found around 13% of Medicare Advantage prior authorization denials were for services that would have been covered under traditional Medicare.

“These denials can create significant negative effects for Medicare Advantage beneficiaries,” the report said.

The U.S. House of Representatives passed a bill Sept. 14 that would reform the prior authorization process for Medicare Advantage plans. The Improving Seniors’ Timely Access to Care bill had bipartisan support and even buy-in from the large insurance companies.

The legislation would require Medicare Advantage companies to set up an electronic prior authorization system and provide real- time approvals for common procedures. It would also beef up transparency requirements and require Medicare Advantage plans to publicly post information about how they deal with prior authorizations.

The bill is now before the U.S. Senate.

This story is available through a news partnership with Capitol Beat News Service, a project of the Georgia Press Educational Foundation.