Aetna rolls back prior authorization requirement for… Leave a comment

Dive Brief:

  • Aetna is no longer requiring prior authorization for cataract surgeries, a controversial policy the payer adopted a year ago, according to a new provider notice.
  • Aetna is also rolling back prior authorization requirements for video EEGs and home infusion for some drugs. It’s adding two new-to-market drugs to the precertification list.
  • The payer said in a statement that it came to its decision after analyzing real-time data from the year the requirement was in place. “Going forward, we will focus on retrospective reviews of procedures and providers where questions of medical necessity exist,” Aetna said.

Dive Insight:

Providers and payers have long been at odds with prior authorization policies, which force a provider to get approval for a procedure or service before it can be performed to qualify for payment. Providers cite delays to care and a build up of red tape, while insurers say that prior authorizations reduce unnecessary care and save money.

Immediately after Aetna’s decided to require prior authorization for cataract surgeries last summer, the American Society of Cataract and Refractive Surgery said the policy would harm patients.

“It is difficult to imagine that Aetna would willingly place its reputation and brand at such a high risk knowing there are studies in peer-review journals detailing increased incidents of injurious falls and automobile accidents as a result of delayed surgery. A prior authorization requirement will delay surgery, will put patients at higher risk, and will alienate patients and physicians,” ASCRS Executive Steve Speares said in a statement at the time.

In a poll conducted this March, nearly 80% of about 650 medical practices surveyed said prior authorization requirements had increased over the past year. And 88% of Medical Group Management Association members surveyed last year said the practice was either “very” or “extremely” burdensome.

The American Medical Association has said prior authorization is an overused tool that results in clinical concerns.


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