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Reverse Total Shoulder Arthroplasty
Published on: July 5, 2011
Prior Authorization Leads to Administrative Burden and Delays in Treatment in Primary Total Joint Arthroplasty
Juan D Lizcano1, Graham S Goh1, Saad Tarabichi1
1Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
Insights
Prior authorization for hip and knee replacements causes significant delays and administrative burdens. Denials often stem from documentation issues, impacting patient access to timely surgical care.
Area of Science:
- Orthopaedic Surgery
- Health Services Research
Background:
- Prior authorization (PA) is criticized for administrative burden and treatment delays.
- The impact of PA on total hip arthroplasty (THA) and total knee arthroplasty (TKA) is not well-documented.
Purpose of the Study:
- To analyze the utilization and impact of prior authorization in a high-volume orthopaedic practice.
- To assess PA approval/denial rates, timelines, and reasons for THA and TKA.
Main Methods:
- Prospective data collection on 28,725 primary THAs and TKAs (2020-2023).
- Analysis included patient demographics, PA status, time to approval/denial, denials, peer-to-peer reviews, and denial reasons.
Main Results:
- PA was required for 56.4% of THA and 54% of TKA cases, with mean approval times of 26.3 and 33.7 days.
- Initial denials occurred in 4.1% of THA and 6.1% of TKA cases, with most overturned after peer-to-peer review.
- Denial reasons included poor documentation and lack of coverage for THA, and unspecified payer reasons for TKA.
Conclusions:
- Prior authorization for elective THA and TKA increases surgical waiting times.
- The PA process imposes a substantial administrative burden on surgeons and healthcare staff.
- Current PA policies may hinder timely access to essential orthopaedic procedures.
Background:
The prior authorization (PA) process is often criticized by physicians due to increased administrative burden and unnecessary delays in treatment. The effects of PA policies on total hip arthroplasty (THA) and total knee arthroplasty (TKA) have not been well described. The purpose of this study was to analyze the use of PA in a high-volume orthopaedic practice across 4 states.
Methods:
We prospectively collected data on 28,725 primary THAs and TKAs performed at our institution between 2020 and 2023. Data collected included patient demographics, payer approval or denial, time to approval or denial, the number of initial denials, the number of peer-to-peer (P2P) or addenda, and the reasons for denial.
Results:
Seven thousand five hundred twenty eight (56.4%) patients undergoing THA and 8,283 (54%) patients undergoing TKA required PA, with a mean time to approval of 26.3 ± 34.6 and 33.7 ± 41.5 days, respectively. Addenda were requested in 608 of 7,528 (4.6%) THA patients and 737 of 8,283 (8.9%) TKA patients. From a total of 312 (4.1%) THA patients who had an initial denial, a P2P was requested for 50 (0.7%) patients, and only 27 (0.4%) were upheld after the PA process. From a total of 509 (6.1%) TKA patients who had an initial denial, a P2P was requested for 55 (0.7%) patients, and only 26 (0.3%) were upheld after the PA process. The mean time to denial in the THA group was 64.7 ± 83.5, and the most common reasons for denial were poor clinical documentation (25.9%) and lack of coverage (25.9%). The mean time to denial in the TKA group was 63.4 ± 103.9 days, and the most common reason for denial was not specified by the payer (46.1%).
Conclusions:
The use of PA to approve elective THA and TKA led to increased surgical waiting times and a high administrative burden for surgeons and healthcare staff.
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