The rates and implications of prior authorizations for advanced shoulder imaging

Shoulder pain is common across all ages and socioeconomic groups. Magnetic resonance imaging (MRI) is vital for diagnosing shoulder pathology, but prior authorizations (PAs) create significant barriers to access. Initially implemented by insurers to control costs, PAs increase administrative burdens on providers, leading to higher costs and delays. While the negative effects of PAs on patient care are documented, their specific impact on shoulder MRI access remains unclear. This study examines trends in PAs for shoulder MRIs and explores associations between PA denials and insurance type, patient demographics, diagnosis, or provider type.

Shoulder MRIs ordered at our institution between December 2021 and September 2023 that required a PA were retrospectively reviewed. Demographics, ordering diagnosis, provider specialty, insurance carrier, insurance type, and third-party authorizing company were collected. Chi-square test and logistic regression analysis using odds ratios were conducted to analyze the relationship between the independent variables and likelihood of PA denial.

Of the 3,532 shoulder MRIs that were ordered, 3,191 (90.1%) required PA. After applying exclusion criteria, 2,499 patients were included, of which 5.8% were denied. Orthopedic surgeons ordered 75.7% of the MRIs, while orders by other providers were 4.38 times more likely to be denied (P = .00). African American patients were 1.62 times more likely to face denials compared to White patients (P = .03), with Hispanic patients also experiencing higher denial rates (P = .05). MRI orders were more likely to be denied by commercial insurance, followed by Medicaid plans, and then managed Medicare plans compared to Medicare D plans (P = .01, .02, and .02). There was a statistically significant difference in denial rates between the 4 different third-party authorization (TPA) companies (P < .001) and 9 different primary payors (P < .001).

The results of this study suggest that multiple factors impact MRI denial rates, including race, provider specialty, TPA service, insurance plan, coverage type, and primary payor. Notably, denial rates were more dependent on insurance carriers or TPA companies than on insurance type (eg, Medicaid vs. commercial). Across the board, certain payors make access to care more difficult, regardless of plan type, tier, or category. Our findings question the utility of PAs for shoulder imaging, with only 5.8% of the PAs resulting in a denial. PAs can delay intervention and place additional cost and time burdens on the health-care system at large.