Prior Authorization

The Academy believes that the time physicians and their staff spend negotiating with insurance companies would be better spent on patient care.

Patients deserve timely access to medically necessary treatment. Too often, prior authorization requirements delay necessary care while adding administrative burdens to physician practices.

We believe insurers should not require prior authorization for routinely approved, medically necessary care, and should limit such requirements for providers with a strong track record of approved procedures. 

Reducing prior authorization burdens is one of the Academy's top advocacy priorities. The Academy-led, multi-specialty, Regulatory Relief Coalition is working to secure prior authorization reform in the Medicare Advantage program. Our coalition is encouraging members of Congress to support the passage of the Improving Seniors' Timely Access to Care Act (H.R. 3514/S. 1816). This bipartisan legislation addresses the lack of transparency, delays to patient care, and physician burdens created by increased prior authorization requirements by MA plans.

We are also urging the Centers for Medicare & Medicaid Services (CMS) to provide stronger oversight of prior authorization requirements. The Academy achieved success with CMS finalizing the Interoperability and Prior Authorization rule (known as the Electronic PA rule), which included many of our policy objectives in reforming the PA process and holding payers accountable.

We continue to push back on CMS initiatives to introduce PA in traditional Medicare, such as through our joint letter to CMS with our Surgical Coalition partners opposing the Wasteful and Inappropriate Service Reduction (WISeR) Model, which was launched on January 1, 2026, to test AI-assisted prior authorization for certain high-risk procedures in traditional Medicare. While ophthalmology-related services are not currently included, we met with CMMI to express our concerns that the model increases administrative burdens on physicians and practices.  

Following a joint letter from the Academy, American Society of Plastic and Reconstructive Surgery, North American Neuro-Ophthalmology Society, and the Outpatient Ophthalmic Surgery Society, and a meeting with CMS, we were successful in getting the agency to push the start dates of the pilot program for PA in ambulatory surgical centers. Now that the pilot program has started, our organizations continue to advocate for improvements to ease the administrative burden on ophthalmology practices and ensure patients have timely access to medically necessary care. 

Prior authorization is a burdensome process that requires physicians to obtain pre-approval for medical treatments or tests before rendering care to their patients. Health insurers frequently require prior authorization for pharmaceuticals, durable medical equipment, and medical services. The process for obtaining this approval is lengthy and typically requires physicians, or their staff, to spend the equivalent of 2 or more days each week negotiating with insurance companies — time that would be better spent taking care of patients. For ophthalmologists, these delays can affect access to time-sensitive treatments for conditions such as wet age-related macular degeneration, diabetic retinopathy, and glaucoma, where delayed care can result in irreversible vision loss.