Prior Authorizations Approvals and Denials: An Analysis From a Large Orthopaedic Practice.

INTRODUCTION: Prior authorization (PA) programs are now pervasive in the healthcare system, designed to promote cost-effective care. However, these programs often result in notable delays and increased administrative workload for providers. Nationally, 93% of physicians report delays in patient care due to PA requirements, and 82% have observed patients abandoning treatment because of these barriers. This study evaluates the operational and clinical impact of PA within a large orthopaedic practice of more than 40 physicians in San Antonio, Texas.

METHODS: A retrospective analysis was conducted using electronic health record data from TSAOG Orthopaedics and Spine (TSAOG). The study included all PA requests for imaging, procedures, and orthopaedic surgeries submitted between January 1 and December 31, 2020. Key metrics assessed were approval and denial rates, delays in patient care, and the financial and staffing resources dedicated to PA management. At TSAOG, a centralized team of authorization specialists manages all PA requests.

RESULTS: This analysis included 30,003 PA requests in 2020. Ninety-seven percent of all requests for authorization were approved first try. An additional 2% of requests were ultimately approved on appeal. Only 1% of requests were definitively denied after appeals. The analysis found that the centralized PA process resulted in substantial operational costs and staff time dedicated to managing authorizations. Care delays and increased administrative burdens were prominent, with many requests requiring appeals and additional documentation, further contributing to resource use.

CONCLUSION: Although PA programs are intended to enhance care quality and reduce unnecessary healthcare spending, this study demonstrates that they frequently impose notable burdens on both patients and medical providers. The substantial delays in care and resource consumption observed at TSAOG reflect a broader national issue. These findings highlight the urgent need for reform in PA processes to ensure that they support, rather than hinder, timely patient care and practice efficiency.