Third-Party Payers: Standing Up for Patients Against Bad Coverage Decisions
Issue
More and more, private insurance companies are floating policy changes that affect our ability to provide our patients with necessary care.
Most recently, Anthem Inc. indicated that it would no longer cover monitored anesthesia during cataract surgery. The Academy believes this is dangerous. For example, a surgeon performing cataract surgery cannot reasonably be expected to monitor anesthesia while performing delicate eye surgery. A sound policy takes into consideration all factors of a procedure, including intensity.
After the Academy challenged this policy, Anthem, Inc., informed us that, despite suggestions otherwise, guidance on monitored anesthesia during cataract surgery is not yet in effect. Still, the guidance was enough to generate widespread confusion and alarm among physicians and the news media. It reminded us as a profession that without vigilance, this and other policies could be enacted, putting our patients’ health at risk.
Anthem has drawn our ire with other questionable policy changes. One in particular involved a 12-state reimbursement cut that was slated to begin in March for office visits bundled with same-day treatment.
Academy Action
As a top issue for our profession, third-party policy decisions are drawing the attention of the Academy’s health policy experts. In response, the Academy is representing ophthalmology in a broad, unified response across medicine.
We're fighting back with a surgical- and patient-centered perspective. It's important that these plans understand what really happens in the operating room and how their policies can make or break a successful surgery.
In response to Anthem’s potentially dangerous policy guidance regarding monitored anesthesia during cataract surgery, the Academy mustered significant opposition from ophthalmology and anesthesiology, along with state and subspecialty societies within ophthalmology. Our efforts resulted in Anthem posting a clarification on its website that the policy is not in effect.
Regarding its modifier -25 decision, Anthem responded to the Academy’s opposition by reversing a planned 25-percent reduction to these appended E/M services. This would’ve reduced reimbursements for the visits associated with intravitreal injections.
We’re also active in identifying new procedures and treatments that warrant coverage. Recently, we urged Humana to cover cornea crosslinking for its 13 million beneficiaries. This procedure helps patients affected by keratoconus and other corneal diseases. We provided copious amounts of peer-reviewed clinical data during our direct discussions with the plan’s leaders.
Ophthalmologists from Connecticut huddle before meeting with Sen. Chris Murphy, Conn., during Congressional Advocacy Day 2018. Their state was among the 12 targeted by Anthem Inc., for a 25 percent reduction to E/M services appended with modifier -25.
Impact
The Academy is finding success by engaging the health plans directly. Humana responded to our advocacy by telling us that it shares our assessment of the value of corneal crosslinking. Humana adjusted its Keratoconus – Surgical Treatments commercial medical coverage policy to meet our request.
We helped convince Anthem to drop its modifier -25 policy change.
The Academy supports ophthalmology on this issue through our vigilance. Our member ophthalmologists in the trenches can continue to support this effort by alerting us to worrisome developments, especially if payments are denied.