The Academy wrote to UnitedHealthcare last week to urge the payer to include ophthalmology services in its new “gold card” program to reduce administrative burdens on physicians and office staff.
The gold card program exempts eligible practices from having to request prior authorization for certain procedures across all in-network UnitedHealthcare plans. The payer’s initial rollout of the program does not include any ophthalmology services.
UnitedHealthcare commercial and individual exchange plans require prior authorization in the hospital outpatient setting (HOPD) for more than 100 ophthalmology codes, including cataract surgery and ocular adnexa procedures. UnitedHealthcare’s Medicare Advantage plan requires site-of-service prior authorization for a limited number of eye surgery procedures.
The policy is designed to ensure most surgeries are delivered in the ambulatory surgery center (ASC) setting. However, many rural ophthalmologists do not have access to a nearby ASC equipped for certain ophthalmology procedures, and some patients’ conditions require their procedures to be managed in the HOPD.
Although UnitedHealthcare covers HOPD-based surgery in either circumstance, the payer still requires physicians to submit documentation for every scheduled procedure before it authorizes a medical necessity exception.
This puts the ongoing administrative burden of requesting prior authorization on ophthalmology practices, even though UnitedHealthcare already has records of a patient’s status and the physician’s ASC access.
Our letter calls on UnitedHealthcare to put an end to redundant site-of-service prior authorizations by extending its gold card program to include applicable ophthalmology practices and procedures.
