Insurance company denying patients sight-saving surgery
If your vision deteriorated so much that you had trouble working or safely driving, would you do everything possible to regain your sight?
Of course, you would.
And as board-certified ophthalmologists, we’ve sworn an oath to do whatever it takes to ensure patients get the medical care they need when they need it.
When we first entered the profession, we could not have foreseen how abusive insurance company practices would become, or how they would take control of medical decisions from doctors and put them in hands of insurance company administrators who delay, disrupt, and sometimes deny medically necessary care.
About 4 million Americans have cataract surgery every year.
It’s one of the most common and lifechanging procedures available. It allows people to see more clearly and resume activities of daily living. Even though cataract surgery is safe, effective, and transformative, Aetna — one of the nation’s largest insurers — has thrown up unreasonable barriers to this sight-saving treatment.
Aetna has told tens of thousands of Americans who have faithfully paid their premiums that their cataracts “are not bad enough” and that their vision must get worse before the insurance company will cover surgery that their physician recommends. A practice called prior authorization gives Aetna this extraordinary power over medical decision making.
Aetna launched a troubling new prior authorization policy on July 1, that applies to all cataracts surgeries — even when patients face emergency situations. This new policy ignores nationally recognized clinical guidelines on cataract care and endangers patients’ health and safety.
Unless Aetna says so, we cannot proceed with surgery even when cataracts are interfering with patients’ work and putting them at increased risk for falls and car accidents.
This absurd policy has already caused 10,000 to 20,000 surgeries to be delayed or cancelled in the first month alone. We’re still fighting with Aetna over one of our patients who came to us in June. She needs surgery for both cataracts and severe glaucoma.
Because vision loss from glaucoma is irreversible, surgery can’t be delayed. Often, both of these eye conditions are treated at the same time because it gives patients the best chance for a good outcome. But here we are, nearly five months later, and Aetna still hasn’t approved the cataract/ glaucoma surgery.
Ordinarily, the precertification process takes less than 15 minutes, but our staff has spent an estimated 15 to 20 hours trying to secure coverage for this one patient alone. She is only in her 60s and has plenty of life to live. For Aetna to deny all appeals and wait for her vision to get even worse before covering her surgery is callous and ignores the standard of care for patients with cataracts and glaucoma.
Recognizing the harm some prior authorization requirements inflict, Congress is working to pass a bipartisan bill that protects patients. The Improving Seniors’ Timely Access to Care Act is designed to put guardrails around prior authorization in Medicare Advantage insurance plans.
The bill already boasts 246 co-sponsors in the House—much more than the 218 necessary to pass— including 10 representatives from Ohio . It was just introduced in the Senate in late October, and our own Sen. Sherrod Brown spearheaded a letter to Medicare urging it to modernize and streamline prior authorization in line with the bill.
As we fight for our patients to get the coverage they pay for, we encourage Ohio’s entire congressional delegation to join. It’s time to protect patient access to sight-saving surgery by stopping insurance overreach.
Dr. Alice Epitropoulos is a boardcertified ophthalmologist specializing in cataract, refractive surgery, and has a dry eye center of excellence.
Dr. Megan Chambers is a board-certified ophthalmologist and fellowshiptrained glaucoma specialist serving central Ohio.