American Academy of Ophthalmology calls on CMS to address Medicare Advantage

The American Academy of Ophthalmology has submitted comments to CMS regarding proposed changes, calling for increased oversight, a reform of prior authorization procedures, step therapy and medical record requests. 

In a letter shared with Becker's on Sept. 8, the academy calls on CMS to improve these key issues. 

"It is clear that increased federal oversight is urgently needed to mitigate harms and reduce unnecessary burdens already existing within our [Medicare Advantage] system," the leader reads. 

It says that prior authorization requirements are heavily burdening Medicare beneficiaries, and encumbering their access to vision care. 

"The Academy fears that MA payers are increasingly applying prior authorization requirements to medically necessary care with minimal clinical basis for doing so. For example, access to sight-saving eye surgery was significantly impeded when Aetna instituted a national prior authorization requirement for all cataract surgeries across all plans, overwhelmingly one of the most common and successful procedures provided by ophthalmologists," it says. 

To fix prior authorization concerns, the academy recommends CMS closely monitor and enforce accountability for plans, reasons for denials, patient outcome data points, and they recommend that CMS share that collected information publicly for patients to access. 

"By creating transparency and accountability around [prior authorization] denial metrics; CMS can work in partnership with MA plans and medical associations to address root-causes of barriers to patient care and ensure the highest patient quality outcomes," the comment reads.

The letter also asks CMS to reinstate step therapy, writing that they are "disappointed by the rescission of this previous standard by the previous administration." 

The letter's third request is that CMS change medical records request policies.

"We have heard from ophthalmologists nationwide that plans are increasingly pushing for high volumes of chart audits and demanding incredibly tight turnaround times to provide the proper documentation. Requests with rapid required response windows may also be misrepresented as a part of Medicare Risk Adjustment Data Validation (RADV) instead of an internal organizational action. In combination, the volume and short timeline for medical records requests create a major demand on the already stretched work hours that office staff have available," it reads. 

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