Magnetic Resonance Imaging Prior Authorizations for Orthopaedic Care Are Negatively Affected by Medicaid Insurance
Samantha Harrer1, Kathryn Hedden, Sadegh Mikaeili
1From the Department of Orthopaedic Surgery (Harrer, Hedden, Gentile, Gealt, and Brown), Department of Orthopaedic Surgery, Cooper University Health Care, and the Cooper University Health Care (Mikaeili and Bazrafshan), Camden, NJ.
Background:
Magnetic resonance imaging (MRI) has revolutionized musculoskeletal care. However, its high costs and high utilization has prompted many insurance payors to require a prior authorization. This process remains burdensome and results in delays to patient care. The purpose of this study was to examine the relationship between several variables and the denial rate of outpatient MRI prior authorization requests from a single institution's department of orthopaedics.
Methods:
MRI prior authorization insurance data was retrospectively collected from January 2019 to December 2022. Patient demographics, imaging characteristics, and insurance details were extracted and stratified into generalized categories. Analysis of variance, multivariate logistic regression models, and odds ratios (ORs) were used to predict the likelihood of request denial with α = 0.05.
Results:
Of the 17,913 total MRI prior authorization requests identified, 885 (4.94%) were denied. Race and socioeconomic status were not markedly different between the authorized and denied cohorts; however, primary insurance payor, chief symptom, and anatomic location to be imaged were found to have notable differences between authorized and denied cohorts ( P < 0.0001). MRIs of the spine were less likely to be authorized compared with the shoulder (OR 0.51), upper extremity (OR 0.43), knee (OR 0.38), lower extremity (OR 0.34), and foot and ankle (OR 0.75) with P < 0.02 for each. Horizon NJ Health and Horizon Blue Cross Blue Shield, both Medicaid payors, were also less likely to authorize requests compared with other payors (Aetna, OR 0.37 and United Healthcare, OR 0.36) ( P < 0.01 for both).
Conclusion:
The low denial rate of initial prior authorization requests over 4 years at our institution underscores the questionable utility of the prior authorization process. Our results are consistent with the current literature that has reported higher rates of denials for MRI prior authorization requests of the spine. Although we were not able to quantify the effect of these denials on patient care, the overall time required to process these requests undoubtedly causes delays in patient care. despite no notable difference seen in socioeconomic status, Horizon NJ Health, a major provider of only Medicaid insurance plans at our institution, was associated with a higher likelihood of denial. This suggests that MRI prior authorization requests submitted for Medicaid patients are more likely to be denied and cause an inequitable delay in care due to this process.
Insights
Magnetic resonance imaging (MRI) prior authorization requests have a low denial rate, but spine imaging and Medicaid patients face higher denials. This process causes delays in patient care.
Area of Science:
- Orthopaedic care
- Health services research
Background:
- Magnetic resonance imaging (MRI) is crucial for musculoskeletal care but faces high costs and utilization.
- Insurance payors often require prior authorization for MRIs, leading to administrative burden and patient care delays.
Purpose of the Study:
- To investigate the relationship between patient/imaging variables and MRI prior authorization denial rates in an orthopaedic department.
- To identify factors influencing the approval or denial of outpatient MRI requests.
Main Methods:
- Retrospective analysis of 17,913 MRI prior authorization requests from January 2019 to December 2022.
- Data included patient demographics, imaging characteristics, and insurance details.
- Statistical methods included ANOVA, multivariate logistic regression, and odds ratios (ORs) to predict denial likelihood.
Main Results:
- A total of 4.94% (885/17,913) of MRI prior authorization requests were denied.
- Spine MRIs had lower authorization rates (ORs ranging from 0.34 to 0.51) compared to other anatomical locations.
- Medicaid payors (Horizon NJ Health, Horizon BCBS) showed lower authorization rates (ORs 0.37, 0.36) compared to other insurers.
Conclusions:
- The low overall denial rate questions the utility of the MRI prior authorization process.
- Spine MRIs and requests from Medicaid patients are more likely to be denied, potentially causing inequitable delays in care.
- While direct impact on care is unquantified, the process inherently delays patient access to necessary imaging.
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