The American Academy of Ophthalmology outlines its top federal advocacy efforts to protect patients and the profession
NEW ORLEANS, La. – As one of the largest specialties in the Medicare program in terms of dollars, ophthalmology is highly affected by Medicare payments set by the Centers for Medicare & Medicaid Services (CMS). These cuts threaten the financial stability of ophthalmology practices across the country. Here’s how the Academy is working to protect them:
1. Medicare Physician Payment Fee Cuts
Physicians are once again facing drastic Medicare payments cuts in January 2022. CMS’ final 2022 Medicare Physician Fee Schedule includes an expected 3.75% cut from budget neutrality requirements and the expiring one-year Congressional fix. On top of that, physicians face a 2% cut from the expiration of a pandemic waiver of the Medicare sequestration cut and a new 4% cut from implementation of “PayGo” balance budget rules triggered by the enactment of the American Rescue Plan Act of 2021. The American Academy of Ophthalmology is working with the American Medical Association and the Surgical Care Coalition to press for Congressional action to derail these cuts.
2. Surgeon and Facility Payments for Cataract and MIGS Codes
In a win for ophthalmology patients, CMS addressed inadequate payments for the new cataract-MIGS surgery procedure in its final rule for 2022. CMS accepted the AMA-Specialty Society Relative Value-scale Update Committee (RUC) recommendations of 12.13 work relative value units (WRVU) for CPT 66989 and 9.23 WRVU for CPT 66991, resulting in a total allowable of $831.56 for 66989 and a total allowable of $663.57 for 66991. The Academy, along with the American Society of Cataract and Refractive Surgery (ASCRS) and the American Glaucoma Society (AGS), strongly disagreed with CMS’ initial proposal of only an additional $34 for MIGS – barely more than standalone cataract surgery. In addition, the agency agreed with the Academy’s recommendation for improved facility paying assigning the combination surgery codes (66989 and 6691) to a new technology Ambulatory Payment Classification code (APC) 1526 with a payment rate of $4,250.50. This will help stabilize payment while complete utilization and cost data can be collected.
3. Global Surgical Payment Equity
Despite strong advocacy from the Academy and other surgical specialties, CMS declined to apply payment equity to post-operative visits included in the Medicare global surgical payments. Traditionally, CMS provides the same payment boost it gives to stand-alone evaluation and management (E/M) codes for office visits to the post-operative visits built into the global surgical payments. Despite productive meetings this year with CMS staff where they acknowledged the urgency to act, the agency did not make the change in the final 2022 fee schedule. As a result, ophthalmologists are losing nearly $200 million a year starting in 2021. The Academy will continue to press for this as a top priority.
4. Prior Authorization and Step Therapy Burdens
Medicare Advantage plans’ prior authorization and step therapy requirements are two of the most burdensome obstacles physician practices face in getting patients the care that they need. Aetna’s recent outlier decision to require prior authorization on all cataract surgery is an excellent example of prior authorization abuse. Ophthalmologists across the country are sharing their patient stories of disruption and delay of medically necessary surgeries. In addition, the Academy has taken several strong actions to fight against these obstacles, including:
- Warning to Beneficiaries: In a 1 media release about Medicare Open Enrollment, the Academy and the American Society of Cataract and Refractive Surgery warned seniors about Medicare Advantage plans with prior authorization and step therapy restrictions that limit access to care.
- Outreach to CMS: In an effort to reverse the decision by the last administration to permit Medicare Advantage plans to impose step therapy on vulnerable patients being treated by Part B/doctor infused or injected drugs, the Academy led a letter with 58 patient and provider groups urging CMS to reverse its dangerous policy. These are patients being treated for cancer, blinding eye diseases, and crippling rheumatologic conditions. Specific examples of patient harm resulting from the policy were presented in a meeting with CMS officials and staff. The Academy continues to press CMS to reverse this policy.
- Advocacy with Congress: We also are working with Congress to pass the Improving Seniors Timely Access to Care Act (HR 3173/S 3018), which seeks to address the lack of transparency, delays to patient care, and physician burdens brought on by increased prior authorization usage by Medicare Advantage plans. The bill recently hit a threshold of a majority of U.S. House members as co-sponsors giving us hope of action soon.
The Academy will continue to advocate for ophthalmologists to have the financial stability they need to care for their patients amid the ongoing pandemic. For more information on the issues that affect ophthalmology, visit www.aao.org.
About the American Academy of Ophthalmology
The American Academy of Ophthalmology is the world’s largest association of eye physicians and surgeons. A global community of 32,000 medical doctors, we protect sight and empower lives by setting the standards for ophthalmic education and advocating for our patients and the public. We innovate to advance our profession and to ensure the delivery of the highest-quality eye care. Our EyeSmart® program provides the public with the most trusted information about eye health. For more information, visit aao.org.