When Prior Authorization Practices Go Too Far

When millions of Americans had to delay or cancel their routine or non-emergent care due to the COVID-19 pandemic last year, it was frustrating, but it also made sense. The health and protection of patients had to come first.

Now, although safety protocols and vaccines are helping physicians resume appointments as usual, thousands of patients remain stuck in a backlog of needed care because their physicians are facing down a different crisis, a crisis that is man-made: an insurance company-imposed pre-approval process for all routine cataract surgeries.

Aetna — the nation’s third-largest insurer — instituted a new preauthorization requirement for all cataract surgeries, effective July 1. It’s a decision that was made with little notice to physicians and without data to support it. For patients who need cataract surgery to restore their vision, the new policy has created delays and disruptions in care. People who need surgery shouldn’t have to fight through a tangle of red tape to receive the care their physicians have prescribed.

Cataract surgery has an extremely high success rate. It enables patients to see clearly again so they can resume daily activities, such as driving and reading. Cataract surgery also helps people avoid injuries from falls or motor vehicle collisions. At times, cataract surgery is urgently required in order to treat other vision-threatening retinal conditions. Approximately 4 million Americans undergo this type of surgery every year without insurance companies questioning their physicians’ judgement. In fact, no other major medical insurer has burdened patients and providers with these unnecessary delays.

But, thanks to Aetna’s recent decision, tens of thousands of Americans are now sitting and waiting in an ever-growing logjam of care. According to the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery, patients have been told that their surgeries could be delayed weeks while their doctors attempt to gain preauthorization. Some providers have been forced to cancel entire weeks of scheduled surgeries because of the policy. An “instant” online approval portal provided by Aetna has been only intermittently operational, forcing healthcare staff to spend hours on the phone to fight for care that their patients need.

When prior authorization emerged two decades ago, it was largely aimed at expensive new diagnostic tests or drug therapies. But today, it seems to serve as a way for insurance companies to practice medicine without a license — making critical healthcare decisions without key information or training, and potentially causing avoidable harm to patients. In fact, the American Medical Association has found that 94% of doctors say their patients have experienced delays in care due to prior authorization — and 30% say the process has led to a serious adverse event for a patient in their care.

Congress can step in and stop this troubling trend for American seniors. The Improving Seniors’ Timely Access to Care Act (H.R. 3173) — currently introduced in the U.S. House of Representatives — is a bipartisan bill that would help rein in prior authorization practices. Although it only applies to Medicare Advantage plans, the legislation would be a significant first step toward reforming a costly, frustrating, and dangerous industry practice that negatively affects patient care.

Prior authorization reforms are also taking place at the state level, though most laws do not go far enough. Advocates and lawmakers should take note of model legislation from the American Medical Association and enact safeguards that protect constituents of all ages from insurers’ prior authorization oversteps.

In the meantime, Aetna must immediately reverse its troubling prior authorization policy for all cataract surgeries so that sight-restoring surgery is not needlessly disrupted.

As we have seen during the COVID-19 pandemic, sometimes care delays — for the safety of patients and providers — are reasonable. But, delaying care so insurers can attempt to save money while usurping trusted providers’ medical decisions is completely unreasonable. And it needs to stop now.

Terry Wilcox is co-founder and executive director of Patients Rising and Patients Rising Now.