Prior authorization to approve TJA may increase surgical wait times, administrative burden
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Key takeaways:
- Patients who needed prior authorization to approve total joint replacement had a mean time overall to approval of 1 month.
- Less than 1% of cases had denials upheld after prior authorization.
GRAPEVINE, Texas — Prior authorization to approve elective total joint replacement may increase surgical wait times and lead to a high administrative burden, according to results presented here.
P. Maxwell Courtney, MD, and colleagues retrospectively collected patient demographics, whether the payer approved the procedure, time to approval or denial, number of initial denials, number of addendums or peer reviews and reasons for denial among 28,857 patients who underwent total hip or knee arthroplasty between 2020 and 2023.
“More than half of all our patients required some type of prior authorization,” Courtney said during his presentation at the American Association of Hip and Knee Surgeons Annual Meeting. “There were some demographic differences between the groups and, again, the insurance types that required prior authorization were more likely to be either commercial or Medicare Advantage because Medicare Part B currently does not require prior authorization for hip or knee replacement.”
Initially, 8% of patients were denied approval to undergo TJA, according to Courtney. He said a request for an addendum occurred in 8.5% of patients for either missing data or additional data required to overturn a denial. Courtney added 104 patients required peer-to-peer review, of which most were associated with whether the procedure required an inpatient or outpatient stay based on the facility.
Patients who needed prior authorization had a mean time overall to approval of 1 month, according to Courtney.
“Of the 14,000 patients that underwent prior authorization, only 53 of them were denied at the end of the day,” Courtney said. “[In] less than 1% of cases, after all of the hoops that we had to jump through, the denials were upheld.”
He added the mean time for denial after completing addendums and peer-to-peer reviews was 2 months. Peer-to-peer reviews and addendums also added 2 weeks to time to approval, according to Courtney.
“After adjusting for all the comorbidities and demographic variables, request for additional information through peer-to-peer or an addendum added an additional 2 weeks to delaying care and it added an associated high administrative cost,” Courtney said.
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Lizcano JD, et al. Paper 51. Presented at: American Association of Hip and Knee Surgeons Annual Meeting; Nov. 2-5, 2023; Grapevine, Texas.
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