Prior Authorization Leads to Administrative Burden and Delays in Treatment in Primary Total Joint Arthroplasty Patients

Background The prior authorization (PA) process is often criticized by physicians due to increased administrative burden and unnecessary delays in treatment. The effects of PA policies on total hip (THA) and knee (TKA) arthroplasty have not been well described. The purpose of this study was to analyze the use of PA in a high-volume orthopaedic practice across four states. Methods We prospectively collected data on 28,725 primary THAs and TKAs performed at our institution between 2020 and 2023. Data collected included patient demographics, payer approval or denial, time to approval or denial, the number of initial denials, the number of peer-to-peer (P2P) or addenda, and the reasons for denial. Results 7,528 (56.4%) patients undergoing THA and 8,283 (54%) patients undergoing TKA required PA, with a mean time to approval of 26.3 ± 34.6 and 33.7 ± 41.5 days, respectively. Addenda were requested in 608 of 7,528 (4.6%) THA patients and 737 of 8,283 (8.9%) TKA patients. From a total of 312 (4.1%) THA who had an initial denial, a P2P was requested for 50 (0.7%) patients, and only 27 (0.4%) were upheld after the PA process. From a total of 509 (6.1%) TKA who had an initial denial, a P2P was requested for 55 (0.7%) patients, and only 26 (0.3%) were upheld after the PA process. The mean time to denial in the THA group was 64.7 ±83.5, and the most common reasons for denial were poor clinical documentation (25.9%) and lack of coverage (25.9%). The mean time to denial in the TKA group was 63.4 ±103.9 days, and the most common reason for denial was not specified by the payer (46.1%). Conclusion The use of prior authorization to approve elective THA and TKA led to increased surgical waiting times and a high administrative burden for surgeons and healthcare staff.