Why Are Ophthalmologists Still Faxing Prior Authorizations?

The Short Answer: The biggest prior authorization category in ophthalmology is drugs, specifically anti-VEGF injections, for which electronic reform has advanced only slowly. Such requests need to include attachments like OCT results, a visual acuity history, and proof that a preferred drug has failed. There is a decline in the electronic handling of these attachments and as a result fax is still widely used. The answer is not to introduce a new channel, but instead to provide full documentation from the examination and to have a team that is well acquainted with each payer’s requirements.

Retina coordinators frequently come across repeating patterns, such as the same patients, medications, payers, and authorizations that expire on dates which seldom correspond with the patients’ injection schedules. Fax machines still do more of this work than many people realize.

This raises a valid question. Most EHRs support electronic prior authorization, and payers have long promised a digital future. In ophthalmology, the issue is less about habit and more about the nature of what is authorized and the required accompanying documentation.

Reason 1: Eye Care’s Biggest Prior Authorization Category Is Drugs

Anti-VEGF injections for wet AMD, diabetic macular edema, and retinal vein occlusion have become prime targets of Medicare Advantage step therapy and prior authorization, and the amount of Part B spending on them has increased. According to a 2023 study in JAMA Health Forum, aflibercept was the second most expensive drug in Medicare Part B in 2020, costing more than $3 billion, and ranibizumab came sixth at over $1 billion.

Federal reform has not yet caught up to drugs. The CMS-0057-F decision timeframes that began January 1, 2026, 72 hours for expedited and seven days for standard requests, do not apply to drugs. A separate proposed rule, CMS-0062-P, would add drug-specific timeframes if finalized. Even the rule’s patient-facing prior authorization data requirements exclude drug requests (CMS fact sheet). For an injection-heavy practice, the ePA era has touched the smallest share of authorization volume. For more about pre authorization prescriptions.

Reason 2: The Request Is Only as Good as Its Attachments

Electronic prior authorization is growing. The 2025 CAQH Index found fully electronic adoption of medical prior authorization rose from 31% to 40%. In the same report, electronic adoption of attachments fell from 32% to 24%.

Ophthalmic authorizations live on attachments.

The American Academy of Ophthalmology notes that step therapy policies may require a lower-cost preferred drug, typically bevacizumab, and a documented failed response before a non-preferred drug is covered, and that each carrier’s policies are unique and change frequently. Proving a failed response means sending OCT findings, acuity trends, injection dates, and treatment history. When staff is not sure a portal will accept all of that cleanly, they send it the way that always works.

Reason 3: The Work Repeats, So the Workaround Sticks

Anti-VEGF patients require ongoing treatment. A large retina database study found that eyes with branch and central retinal vein occlusion received an average of seven injections in the first year (Ophthalmology Retina00251-9/fulltext)). Some payer policies cap annual doses per eye or limit approval duration, causing authorization work to repeat with each injection cycle. As a result, the most reliable channel, often fax, becomes the standard process.

This routine has high costs. A Tennessee retinal practice saw staff costs rise 63% from 2024 to 2025, mainly because of prior authorization demands. A New York practice increased full-time clerical staff from 6.25 to 7.4 per physician between 2019 and 2024. Research estimates each anti-VEGF prior authorization adds approximately $640 in societal costs. The AMA’s latest survey found practices average 40 prior authorizations per physician weekly, requiring about 13 hours of physician and staff time.

The Real Question Is Not Fax or Portal. It Is What Is in the Chart.

Experts note that prior authorization approval rates for retina therapies are already high, suggesting the process may primarily add delays and workload without affecting prescribing decisions (AJMC). The objective should be to secure approval on the first submission, promptly, and without duplicating efforts.

Simply moving requests to a portal does not resolve these issues. The key is ensuring the chart contains all information payers require:

None of this is clinical judgment by the documentation and authorization team. The ophthalmologist chooses the treatment, and the AAO’s Preferred Practice Pattern states that the choice of reference, biosimilar, or interchangeable product should belong to the treating ophthalmologist and the patient whenever possible (AAO Age-Related Macular Degeneration PPP). The support team’s job is to make sure that decision, and the evidence behind it, reaches the payer in the form the payer requires.

Why JCAHPO Certification Matters

The International Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO) has offered certification and continuing education for ophthalmic allied health personnel since 1969, and more than 34,000 people have earned its certification.

JCAHPO’s Ophthalmic Scribe Certification (OSC®) tests the knowledge needed to create and maintain patient records under the supervision of an ophthalmologist. The 125-question exam covers ten core areas, including electronic health records, history taking, ophthalmic abbreviations and acronyms, anatomy, pharmacology, and terminology.

DataMatrix Medical is JCAHPO-certified; our ophthalmic scribes hold the Ophthalmic Scribe Certification. This is important for authorizations because scribes with expertise in ophthalmic abbreviations, pharmacology, and anatomy are less likely to omit laterality, miss OCT findings, or record drug histories too vaguely to support step therapy exceptions. Accurate documentation reduces stalled requests, regardless of the submission channel.

Learn more about our JCAHPO-certified ophthalmic scribes.

Where Experience Matters More Than the Channel

Most practices buy documentation help from one vendor and authorization help from another, then spend staff time closing the gap. DataMatrix Medical supports both, which is where the other reasons ophthalmology practices choose us come in:

• Ophthalmology-specific prior authorization. Retinal injections, corneal transplants, glaucoma procedures, orbital decompression, and more, from submission through follow-up and appeals. See our prior authorization services for ophthalmologists.
• Channel knowledge that does not walk out the door. Our team knows which payers handle which requests electronically, which still work best by fax, and how to verify delivery either way, so nothing depends on one staff member being in that day.
• A proven prior authorization record. A prior authorization denial rate under 1% across our book of business, with every request human-reviewed for payer criteria and documentation completeness.
• 25 years of healthcare operations. A fully US-based team supporting 300+ practices across 35+ specialties.
• Eligibility verification. Confirming medical versus vision coverage and authorization requirements before the visit, not after the claim.
• EHR-agnostic support with integrated backup scribe coverage and no long-term contracts.

What Ophthalmology Practices Can Do Now

1. Audit both channel and outcome. Review a month of authorizations, categorizing each by type (drug, surgery, imaging), channel, and result. If fax and portal requests stall at similar rates, the channel is likely not the bottleneck.
2. Develop an injection authorization calendar. Track each patient by eye, drug, authorization expiration, and annual dose cap to ensure re-authorizations begin before the next injection is due.
3. Standardize step therapy documentation by creating consistent chart fields for prior drug, dates, number of injections, OCT response, and acuity trends.
4. Obtain proof of delivery for every fax. Use tracked methods with confirmation to prevent lost requests from requiring resubmission.
5. Verify medical and vision benefits for each episode of care. Routine and medical eye care often have separate coverage, which affects authorization requirements.
6. Monitor drug policy and regulatory changes. Preferred product and biosimilar policies evolve, and CMS-0062-P could alter drug decision timeframes if finalized.

The Question for Your Practice

If every fax in your office were replaced by portal submissions tomorrow, would your re-authorizations move faster, or would the same missing details simply arrive sooner?

Frequently Asked Questions

Sources

• • Managed Healthcare Executive: Step Therapy Associated With More Switching of Anti-VEGF Treatment
  • Ophthalmology Retina: Treatment Patterns and Long-term Outcomes with Anti-VEGF Therapy for RVO00251-9/fulltext)
  • AAO: Prior Authorization for Retina
  • Ophthalmology Advisor: Step Therapy, the Safe Step Act, and Ophthalmology’s Support
  • CMA: AMA Survey Highlights Ongoing Prior Auth Burdens
  • AJMC: Role of Prior Authorization in Accessing Anti-VEGF Therapies
  • AAO: Age-Related Macular Degeneration Preferred Practice Pattern
  • American Council on Education: IJCAHPO
  • JCAHPO: Ophthalmic Scribe Certification
  • AJMC: CAQH Index Finds $20 Billion in Cost Savings Opportunities (2025 CAQH Index)
  • CMS Fact Sheet: CMS-0057-F