Prior authorization may be an ineffective, costly barrier for patients undergoing TKA
Key takeaways:
- Patients who required prior authorization had increased costs in the year prior to TKA.
- Prior authorization was not effective in determining who was a good surgical candidate, researchers said.
SAN DIEGO — Prior authorization may be a barrier to cost-effective care for patients undergoing primary total knee arthroplasty, according to results presented here.
“All of the nonoperative and conservative therapies that patients are required to trial before they even get to the point of having or scheduling surgery increased costs,” Elizabeth Abe, BS, a medical student at the Rothman Institute, told Healio about results presented at the American Academy of Orthopaedic Surgeons Annual Meeting. “Not only is it not cost-effective, but it actually increases costs.”
Abe and colleagues retrospectively analyzed data from 4,289 commercially insured patients undergoing primary TKA from 2020 to 2022 to determine the costs associated with obtaining prior authorization. Patients were categorized into groups depending on whether they required prior authorization (n = 2,906) or not (n = 1,832).
Outcomes measured included prior authorization status, time to approval or denial, number of denials, reason for denials, number of office visits and the cost of nonoperative treatment received prior to TKA.
According to Abe, patients who required prior authorization had significantly increased costs in the year prior to TKA vs. patients who did not require prior authorization. She also said every patient included in the study ended up having surgery, “which goes to show that prior authorization was not effective in truly determining who was and was not a good surgical candidate in terms of disease progression or how severe it was.”
Abe said future research should determine the effect of prior authorization on different insurance types.
“Now, we want to go outside of commercial insurance and look at Medicare Advantage,” Abe said.
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Abe E, et al. Paper 82. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 10-14, 2025; San Diego.
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