Prior Authorization Leads to Administrative Burden and Delays in Treatment in Primary Total Joint Arthroplasty...

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.