ASCRS News
December 2022
by Brad Gruehn, ASCRS Chief of Government Relations, and Jillian Winans, ASCRS Senior Manager of Government Relations
In a major victory for ophthalmologists and their patients, ASCRS’ advocacy led one of the largest insurers in the nation to rescind its harmful prior authorization policy for cataract surgery in nearly every state, and it continues the fight to prevent other prior authorization policies from being implemented. ASCRS has been pushing for Medicare payment reform and urging Congress to take immediate action to stop the 8.5% Medicare payment cut slated to go into effect on January 1, 2023. Additionally, ASCRS seeks fair payment for postoperative services included in 10- and 90-day global surgical packages.
Prior authorization
As of July 1, 2022—1 year after enacting its policy—Aetna dropped its prior authorization requirement for cataract surgery for all lines of business and all sites of service, including Medicare Advantage plans, in every state except Florida and Georgia. This decision came after a year-long advocacy effort led by ASCRS, in collaboration with AAO, and significant grassroots involvement by ASCRS and ASOA members.
Thanks to ASCRS and ASOA members, numerous personal stories were sent to Aetna leadership detailing the harmful impact this policy had on their patients and practices. Additionally, ASCRS and AAO engaged in a joint public relations campaign that yielded nearly 200 media placements in targeted markets nationwide, educating the public about the negative impact of this policy. ASCRS and AAO also continued to have meetings with Aetna leadership and engaged federal lawmakers on the issue. As a result, Representative Mariannette Miller-Meeks, MD (R-IA), and Senator Rand Paul, MD (R-KY), both ophthalmologists, sent letters to the Centers for Medicare & Medicaid Services (CMS) expressing concern for the new policy and its impact on patients. Following this outreach, CMS sent a letter to Aetna that outlined ASCRS’ concerns.
In an ASCRS press release, ASCRS Government Relations Chair Parag Parekh, MD, expressed his thoughts. “Almost a year to the day, I spoke about how I was sad and angry to have to cancel cases that were arranged months ago, delaying patient care, due to this poorly reasoned prior authorization policy,” Dr. Parekh said. “For the past year, it has been a challenge to grapple with this requirement when I saw patients needing cataract surgery, but the insurer ultimately decided on medical necessity. It has also been a burden from a practice management standpoint. I am glad to again have the authority, as the surgeon, to determine what is best for my patients and when.”
Even with this success, the ASCRS Government Relations team continues to be vigilant against harmful prior authorization policies that threaten patients’ access to timely care. ASCRS continues to work on addressing the Aetna prior authorization policy in the remaining two states and is pushing to stop other prior authorization policies impacting anterior segment surgeons.
On Capitol Hill, bipartisan legislation supported by ASCRS, the “Improving Seniors’ Timely Access to Care Act of 2021” (H.R.3173), was approved by voice vote in the U.S. House of Representatives on September 14. The House bill, sponsored by Representative Suzan DelBene (D-WA), had 326 bipartisan cosponsors at the time of its passage. The Senate companion bill (S. 3018), sponsored by Senator Roger Marshall, MD (R-KS), had 45 bipartisan cosponsors as of October 11.
H.R. 3173/S. 3018 would establish requirements that would modernize and streamline the prior authorization processes under Medicare Advantage plans. Specifically, Medicare Advantage plans would have to: (1) establish an electronic prior authorization program that meets specified standards, including the ability to provide real-time decisions in response to requests for items and services that are routinely approved; (2) annually publish specified prior authorization information, including the percentage of requests approved and the average response time; and (3) meet other standards, as set by CMS, relating to the quality and timeliness of prior authorization determinations. ASCRS and its colleagues in the medical community are advocating for this bill to be approved by the Senate and enacted into law before the end of the year.
ASCRS continues to urge CMS to increase its oversight of Medicare Advantage plans to ensure they are not unnecessarily delaying or denying beneficiaries’ access to care through prior authorization policies. ASCRS maintains that prior authorization should not be required for cataract surgery, given that it is one of the most common and efficacious Medicare surgical procedures, and most Medicare beneficiaries will require it at some point to maintain functional vision.
Medicare payment reform
ASCRS remains concerned about the growing financial instability of the Medicare Physician Fee Schedule (MPFS) and anterior segment surgeons’ reimbursement. Annual Medicare physician payment cuts are unsustainable, especially for solo and small practices struggling to provide patient care due to rising inflation costs, workforce shortage issues, and the financial effects of the COVID-19 public health emergency. In order to address the instability of the MPFS, ASCRS and the medical community are working together, urging Congress to take action. As part of the American Medical Association (AMA) Workgroup on Medicare Reform, ASCRS helped develop a set of principles to address the systemic problems with the Medicare physician payment system to ensure continued patient access to care. The principles, in general, call on Congress to provide financial stability through an annual inflation update, reward the value of care provided to patients and encourage innovation, and advance health equity and reduce disparities.
In September, a bipartisan group of U.S. representatives issued a request for information seeking feedback on actions Congress could take to stabilize and improve the Medicare payment system. ASCRS worked with colleagues in the Alliance of Specialty Medicine to develop a response highlighting the need for an inflation update for physician payments and the need to address budget neutrality in the MPFS, as CMS does not have the authority to address this issue.
Additionally, ASCRS continues to work with the medical community urging Congress to avert the roughly 8.5% cut in Medicare payment scheduled to take effect on January 1, 2023. In late September, ASCRS joined more than 100 medical organizations (representing more than 1 million healthcare professionals) expressing support for legislation in the U.S. House of Representatives (H.R. 8800) that would address the 4.5% cut to the Medicare conversion factor in calendar year 2023 and call on Congress and the administration to ensure financial stability and predictability in the Medicare physician payment system going forward. In addition to supporting H.R. 8800, ASCRS is urging Congress to address the 4% pay-as-you-go (PAYGO) cut due to a previously unpaid for sequestration bill in Congress that addressed COVID-19.
Global surgical payments
ASCRS maintains strong opposition to CMS’ policy that has not equitably applied the 2021 increased values of standalone evaluation and management (E/M) services to the postoperative E/M visits in 10- and 90-day global surgical codes for calendar year 2023. CMS implemented the AMA RVS Update Committee (RUC)-recommended increases to standalone E/M services for calendar year 2021 and other select bundled services and codes but is not following the RUC’s recommendation to extend those increases to global surgical postoperative services. ASCRS maintains that by not applying these increases, CMS is distorting the relativity of the MPFS and creating inequities among physicians. ASCRS maintains that at a minimum, for all 10- and 90-day global surgical codes that have been recently revalued and confirmed by CMS, such as the cataract surgical codes, the agency should adjust the E/M payment immediately to reflect the updated payment increases applied to the standalone E/M codes that were implemented on January 1, 2021.
At the behest of ASCRS, AAO, and other surgical specialty colleagues, Representative Ami Bera, MD (D-CA), and Representative Larry Bucshon, MD (R-IN), sent a letter to CMS in September expressing their concern with the agency’s policy that does not appropriately value E/M office visits within the global surgery code and urging CMS to adjust the global codes in the calendar year 2023 MPFS final rule. In their letter, they noted the calendar year 2021 rule marked the first time ever CMS revalued the office/outpatient E/M codes without also updating the global surgical code values.
For more information about these activities or ASCRS’ other legislative and regulatory advocacy efforts, contact the ASCRS Government Relations team.
Contact
Gruehn: bgruehn@ascrs.org
Winans: jwinans@ascrs.org
