Advocacy News

The insurer will require preapproval for 19 ophthalmic procedures in hospital outpatient department covered by its Medicare Advantage plans starting May 1

A new Office of Inspector General report has found that tens of thousands of patients enrolled in Medicare Advantage plans are denied necessary care and misuse of prior authorization.   

The Academy and partner groups educated the Department of Health and Human Services Office of the Inspector General on modifier -25 in an effort to end unnecessary audits.

Nine out of 10 physicians surveyed by the American Medical Association said for patients whose treatments required prior authorization, the process had a somewhat or significant negative effect on their clinical outcomes. The Academy continues to work with our members and partners to press for reform.

The Centers for Medicare & Medicaid Services has acceded to Academy-led efforts to eliminate or at least reduce the unnecessary burden imposed by CMS’ prior authorization program for hospital outpatient department services, including removing CPT code 67911, a type of corrective lid surgery, from the list.

We’re concerned that new national standards would override state scope-of-practice laws and other veterans’ patient safety policies.

We continue to sound the alarm about the harm caused by elimination of the ban on step therapy for Part B drugs in Medicare Advantage plans.

CMS has told Medicare Advantage plans that the two biosimilars, which are not clinically proven to treat eye disease and are potentially dangerous to ophthalmology patients, may not be used as substitutes for Avastin or be required in their step therapy programs.

The Centers for Medicare & Medicaid Services has finalized a payment increase for hospital outpatient departments and ambulatory surgery centers in its 2022 Medicare Hospital Outpatient Prospective Payment System and the Ambulatory Surgical Center (ASC) Payment System rule. This rule affects hospital outpatient departments and ambulatory surgery centers only.

Overall rate increases of 2.3%, yes. Extended pass-through status for some drugs and biologics, yes. Inadequate payment for newly combined MIGS and cataract codes, no.