Georgia’s Medicare Advantage Beneficiaries Get Relief from Abusive Prior Authorization Policy

SAN FRANCISCO, Calif. – The American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery (ASCRS), and the Georgia Society of Ophthalmology applaud Humana for rolling back its prior authorization requirement for cataract surgery for Medicare Advantage beneficiaries in Georgia. Last year, Humana began requiring pre-approval through iCare Health Solutions for all cataract and posterior capsulotomy (or YAG laser capsulotomy) surgeries. This irrational policy caused unnecessary treatment delays and denials for people in Georgia who needed surgery to restore their sight. Humana’s decision is effective August 1.

When Humana announced its new policy last August, the Academy teamed up with the Georgia Society of Ophthalmology and ASCRS to provide documented patient cases that substantiated the need to rescind this disruptive policy. The organizations made sure the insurer heard the voices of patients in Georgia who were harmed by unnecessary care delays and ophthalmologists whose practices struggled under a burdensome approval process.

“We commend Humana for listening to patients and physicians and removing barriers to timely cataract surgery,” said Stephen D. McLeod, MD, CEO of the Academy. “Requiring approval for a routine, well-established procedure only serves to delay a transformative treatment, and bind physicians in unnecessary red tape.”

Cataract surgery is a common procedure with some 4 million Americans undergoing cataract surgery each year. It has an extremely high success rate with regards to safety and vision improvement, and studies have consistently shown that cataract surgery improves quality of life, lowers the risk of falls and car accidents, and is associated with reduced cognitive decline amongst older adults.

The fight to protect cataract surgery patients from prior authorization began two years ago when Aetna, the nation’s third-largest health insurer, instituted a sweeping and unprecedented new policy requiring pre-approval for all cataract surgeries.

After a year of sustained advocacy from the ophthalmology community, Aetna rescinded its policy in July 2022 – except for people enrolled in Medicare Advantage in Florida and Georgia. One month after Aetna’s partial reversal, Humana instituted its own prior authorization policy for cataract surgery patients living in Georgia.

“Georgians enrolled in Medicare Advantage through Humana and Aetna have been inexplicably and unfairly targeted for prior authorization policies,” said Purnima Patel, MD, president of the Georgia Society of Ophthalmology. “We’re relieved for our cataract patients enrolled in Humana, and we will continue to fight for our patients enrolled in Aetna’s Medicare Advantage plans.”

“While we’re encouraged by Humana’s decision to rollback its policy, the fight to protect our patients is not over,” said Parag Parekh, MD, government relations chair for ASCRS. “We will continue to pressure Aetna to retract its policy for people enrolled in Medicare Advantage in Florida and Georgia.”

The ophthalmology community has long worked to change how prior authorization works for all of medicine, not just patients who need cataract surgery. The Academy is a founding member of the Regulatory Relief Coalition, a group of national physician specialty organizations advocating for regulatory burden reduction in Medicare.

The Academy, along with the Coalition, helped craft the Improving Seniors’ Timely Access to Care Act, legislation that would require Medicare Advantage plans to streamline prior authorization processes and improve the electronic exchange of health data. 

Last month, the House Committee on Ways and Means passed out of committee legislation that broadly incorporates the reforms proposed in the Improving Seniors’ Timely Access to Care Act. The Academy is urging Congress to seize on this momentum and get commonsense prior authorization reforms signed into law this year.

“We need to protect all patients from irrational policies that delay and deny necessary medical care,” Dr. McLeod said. “Medicare Advantage plans have greatly expanded the use of prior authorization over the years, putting profits over patients. Reform is desperately needed now.”