Prior Authorization in Joint Arthroplasty Surgery: Navigating Challenges

Prior authorization (PA) is a management process used by payors to regulate whether a procedure will be approved and covered as part of a patient's care plan. The reported benefit of PA is to improve the value and quality of care delivered to patients by ensuring appropriate treatments. However, in practice, it is often viewed as a payor-driven cost-control measure, creating barriers within the field of arthroplasty care for both surgeons and patients to access medically indicated treatment. Prior authorization can create substantial hurdles for arthroplasty surgeons, especially in securing surgical authorizations, imaging requirements, and navigating viscosupplementation approvals. These obstacles not only delay procedures but can also delay and jeopardize patient outcomes. This article explores the impact of PA on joint arthroplasty surgery, the historical context of the PA system, strategies to minimize denials, and relevant upcoming legislative efforts to reduce its impact.