Prior Authorization in Total Joint Arthroplasty: Evaluating the Impact on Patient Care

Prior authorization (PA) in total joint arthroplasty (TJA) can challenge patients and providers. This study examines how site-of-care decisions impact outcomes by comparing patients approved for inpatient vs outpatient surgery, with the goal of improving PA processes and guiding best practices.

PA data from primary TJA (n = 1030) cases were retrospectively collected at a tertiary academic center from June to December 2022. Variables included demographics, comorbidities, American Society of Anesthesiologists (ASA) score, insurance type, submission method, and site-of-care request. Cohorts were analyzed by site-of-care determination, time to decision, length of stay, and complications. Statistical analysis used Chi-square and t-tests.

PA was required for 81% (n = 736) of inpatient TJA cases, with a 90% (n = 661) approval rate. Approved inpatient cases were associated with older age (64.3 ± 10, P = .04), women (n = 464, 74%, P < .01), ASA class 3-4 (n = 334, 53%, P < .01), and higher body mass index (33.2 ± 6.7 kg/m2, P < .01). Thirty percent of requests used noninternet methods, with Managed Medicare patients accounting for 53% (n = 343). Median time to decision was 4 days (range 0-37). Only 30% of patients denied inpatient admission achieved same-day discharge. No significant differences in postoperative complications were observed.

PA significantly influences TJA patients and providers, with most cases requiring PA. Approval was influenced by site-of-care request, age, sex, health status, and insurance type. Frequent noninternet submissions and prolonged decision times identify areas for improvement overall.