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The California Academy of Eye Physicians and Surgeons (CAEPS) is the only statewide organization representing California ophthalmologists and their patients. CAEPS' activities include public education about important eye health care concerns, legislative advocacy, interaction with third party payers about reimbursement and coverage issues, and continuing medical education for ophthalmologists and their staffs.
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Aetna "blurs the line" with Cataract Surgery precertification
In July, Aetna – the nation’s third-largest provider of health insurance and services – implemented a policy that is in complete contradiction of its stated commitment (see 2018) to build an “open health care model that will help consumers improve their health and simplify their health care experience.” Specifically, Aetna is now requiring precertification for all cataract surgeries without any clear explanation.
During a meeting with CAEPS’ national counterpart – the American Academy of Ophthalmology (AAO) – Aetna admitted that its own internal calculations found that there would be less than a 5 percent chance that it would deem a surgery “unnecessary.” Yet, they are implementing this policy that could negatively affect more than 95% of beneficiaries.
“Visual impairment due to cataract is real, reduces our patients’ quality of life, interferes with their work, and puts them at increased risk for falls and car accidents,” said Craig H. Kliger, MD, Executive Vice President of CAEPS. “About 4 million Americans undergo cataract surgery every year, a number that will grow as our population ages.” He recently penned an Op-Ed that appeared on the Sacramento-based political website Capitol Weekly.
CAEPS, the California Medical Association, and the American Academy of Ophthalmology working in concert, have asked Aetna to immediately withdraw the program, which – because Aetna published no updated policy documents and provided limited prior education before implementation -- is already causing chaos at doctors’ offices and places where surgery is performed.
“Uncertainty in regard to whether or not a surgical procedure will be covered is untenable when expensive supplies and facilities are involved,” said Kliger. “There must be a better way for Aetna to address whatever issue they are trying to fix. It is imperative that a different solution is implemented in order to avoid delays or potentially denying our patients access to vision-restoring surgery.”
The AAO estimates that 10,000 to 20,000 Aetna patients had their cataract surgery unnecessarily delayed in the month of July alone, and frequently patients have been blaming ophthalmologists for surgical cancellations that are beyond their control. In short, this policy threatens to erode trust between patients and physicians, seemingly for no real benefit.