More Money, More Problems: Prior Authorization Is a Barrier to Cost-Effective Care in Primary Total Knee Arthroplasty

While prior authorization (PA) was originally intended to reduce unnecessary healthcare utilization, evidence now suggests that its use results in an increased administrative burden and delayed access to care. To our knowledge, the financial burden and proposed cost-effectiveness of PA in total knee arthroplasty (TKA) are yet to be determined. The purpose of this prospective study was to quantify the costs associated with obtaining PA in primary TKA patients.

All commercially insured patients undergoing primary TKA from 2020 to 2022 at our institution were included. Data on PA status, time to approval or denial, number of denials, and denial reasons were prospectively collected. Additionally, the number of office visits and overall costs of nonoperative treatment received in the year before TKA and from initial PA request to date of surgery were also recorded.

A total of 4,289 patients were included in the analysis. Of these, 2,906 (67.8%) patients required PA and 1,383 (32.2%) did not. Mean cost in the year before TKA was higher in patients who required PA before surgery ($716±814 versus $645±688, P = 0.005). We also found that the mean cost from request date to date of surgery was significantly greater in the PA cohort ($166±238 versus $85.7±87.9, P = 0.002). The main cost drivers in the PA cohort during the year before TKA were office visits followed by x-rays. Upon multivariate regression, any addendum requirement was found to increase costs from the request date to the date of surgery by $102 (P = 0.047).

In the present study, obtaining PA in patients undergoing primary TKA paradoxically increased costs in both the year before TKA and from the initial request date to the date of surgery. Future studies are needed to gain a better understanding of the PA approval process.