Cataract surgeries subject to Medicare Advantage requirements for some in Georgia – but not in other states  |


ATLANTA – Georgians who’re 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 necessities are burdensome and don’t apply in most other states.

The issue began last 12 months when Aetna began requiring prior authorizations for cataract surgeries in its Medicare Advantage plans across the country. 

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

Six weeks ago, Humana, one other large Medicare Advantage insurer, enacted the same policy requiring prior authorizations for cataract surgeries in Georgia. 

Georgia eye doctors say Aetna and Humana’s latest requirements force them to have interaction in lengthy back-and-forths over billing for what needs to 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 – as a substitute of 1 week – upfront to permit additional time for the prior approval process. 

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

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

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

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

“It sort of surprised me that somebody would take a look at this as something that is a few kind of extra advantage of health care, which really needs to be the usual of care,” she said. “It’s … an unnecessary burden on these old folks which are struggling already with their vision.”

Cataracts cloud vision and make people more at risk of falls and auto accidents. They’ll even contribute to increased dementia risk, in response to a recent study.

Most adults will need the procedure sooner or later, ophthalmologists say, and it’s highly effective and protected. The procedure is one of the vital common surgeries in america and may be performed at an outpatient surgery center or at a hospital, in response to the National Eye Institute. 

Greater than half of Georgians enrolled in Medicare, the federal insurance program for adults 65 and older, are members of personal Medicare Advantage plans slightly than the standard Medicare program for his or her medical insurance, in response to the Kaiser Family Foundation. 

Older Americans can enroll in Medicare Advantage plans through private medical insurance corporations as a substitute 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 corporate said. Federal data indicate Aetna has about 133,000 Medicare Advantage members in Georgia, although the corporate wouldn’t confirm the number. 

Humana and Aetna said their different Medicare Advantage policy in Georgia is on account of a pre-existing relationship with Florida-based iCare Health Solutions, a contractor that handles eye-care claims 

“The explanation for this transformation is to higher 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 make sure prompt replies to all requests.”

Aetna analyzed “real-time data” about cataract surgeries for a 12 months and, based on its findings, decided to discontinue the prior authorization policy earlier this 12 months, said Kimberly Eafano, a spokesperson for the corporate, which is owned by CVS. 

However the situation in Georgia and Florida is different, she said. 

“Aetna has been engaged in a 10-year relationship with iCare Health Solutions to administer ophthalmology and optometry services in Florida,” Eafano said. “Almost two years ago, Aetna expanded this arrangement to incorporate the state of Georgia, where iCare also has a community presence.”

Officials from iCare didn’t reply 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 very own decisions about covering services but, typically, Advantage plans should follow traditional Medicare’s coverage guidelines.  

“Medicare Advantage plans may apply internal coverage policies, including additional coverage requirements to higher define the necessity for the service, which are no more restrictive than traditional Medicare’s national and native coverage policies,” he said. 

“For services that usually are not subject to existing local and national coverage requirements, Medicare Advantage plans may apply third-party guidelines, corresponding to guidelines utilized by contractors engaged by the Medicare Advantage plan to make coverage determinations.” 

Spokespersons for the Georgia Attorney General and the state Department of Insurance each 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 within 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 might 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 might 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 big insurance firms. 

The laws would require Medicare Advantage corporations to establish an electronic prior authorization system and supply real-time approvals for common procedures. It might also beef up transparency requirements and require Medicare Advantage plans to publicly post details about how they take care of prior authorizations. 

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

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


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