January 29, 2018
Area(s) of Interest: Commercial Payors Patient Care Payor Issues and Reimbursement
On December 27, 2017, Anthem Blue Cross implemented a clinical guideline that restricts the use of intravenous anesthesia to sedate patients during cataract surgery. The California Medical Association (CMA) believes this drastic change in policy will cause significant patient safety concerns and put patients at risk of serious complications, including blindness.
The new policy deems intravenous anesthesia not medically necessary, except in very narrow circumstances. Anthem patients wishing to have any form of intravenous anesthesia during the procedure will now be forced to pay out of pocket.
“The policies around cataract surgery are vital to patient safety,” said David H. Aizuss, M.D., an ophthalmologist and CMA president-elect. "Anthem's newest policy change falls below the standard of care, and it follows a disturbing pattern of putting patients at risk to make a profit."
In addition to the patient safety issue, CMA is also concerned about the legality of this new policy, as it is inconsistent with California law that requires health plans to prove that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management (Health & Safety Code §1367(g)). The policy also conflicts with Anthem’s obligations under to cover essential health benefits (Health & Safety Code §1367.005(a)).
CMA is further concerned that Anthem failed to properly notify contracted physicians of this material change, as required by state law (Health & Safety Code §1375.7(b)(1)(B)). CMA has asked the CaliforniaDepartment of Managed Health Care (DMHC) and the California Department of Insurance (CDI) to investigate and require Anthem to rescind the policy retroactive to the effective date.
“Anthem's predatory practices and policies are increasing in intensity, frequency and with complete disregard for their impact on California's health care delivery system," said Theodore Mazer, M.D., CMA president. “We urge the DMHC and the Department of Insurance to intervene when insurers functionally block access to services that are widely viewed as the standard of care."
Both the California Academy of Eye Physicians and Surgeons and the California Society of Anesthesiologists recently expressed similar patient safety concerns with the policy in letters to Anthem and asked the plan to urgently rescind the policy.
Anthem amended the policy on February 1 to clarify that it did not intend to exclude “moderate sedation” from coverage, but that such sedation would have to be managed by the surgeon. Because cataract surgery is very precise work, it is risky for a surgeon to divide time between the two tasks. Therefore, a qualified anesthesia provider would be both required and requested in all situations when sedation is needed (the vast majority of current cataract surgery cases), making the activity “monitored anesthesia care,” which the policy still excludes except under extreme exceptions.
What actions can physicians take?
Anesthesiologists who have received a medical necessity denial for IV sedation during cataract surgery since the implementation of the policy may wish to help their patient file an independent medical review (IMR) with the regulator. Physicians can also file an IMR on behalf of their patient if the patient authorizes the physician to do so.
For DMHC-regulated products, in order for the physician to file on the patient’s behalf, the patient must complete the “Authorized Assistant Form.” To file for IMR, visit the DMHC’s IMR webpage.
For CDI-regulated products, in order for the physician to file on the patient’s behalf, the patient must complete the “Authorization for release of medical records and designation of independent medical review agent” form (see page three). To file for IMR, visit the CDI’s IMR webpage.
For more information on Independent Medical Reviews, see CMA’s On-Call Document #7155, "Independent External Medical Review."
If a physician determines that a patient requires IV sedation for a cataract surgery, CMA recommends the doctor review his/her contract to understand any patient billing restrictions. Many contracts prohibit physicians from collecting directly from patients for services deemed not medically necessary unless the patient signs the “Covered Individual Patient Responsibility Agreement – Waiver Letter” prior to the procedure.
If your practice and patients are affected by this policy change, are receiving medical necessity denials for anesthesia services for cataract surgery since the effective date, or your practice did not receive the required advance notice of the change, please contact CMA at (888) 401-5911 or firstname.lastname@example.org.