Abstract：
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 arthroplasty (THA) and total knee arthroplasty (TKA) have not been well described. The purpose of this study was to analyze the use of PA in a high-volume orthopaedic practice across 4 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: Seven thousand five hundred twenty eight (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 patients 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 patients 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%).
CONCLUSIONS: The use of PA to approve elective THA and TKA led to increased surgical waiting times and a high administrative burden for surgeons and healthcare staff.
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: Seven thousand five hundred twenty eight (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 patients 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 patients 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%).
CONCLUSIONS: The use of PA to approve elective THA and TKA led to increased surgical waiting times and a high administrative burden for surgeons and healthcare staff.
摘要：
背景：由于增加的行政负担和不必要的治疗延误，事先授权（PA）过程经常受到医生的批评。PA政策对全髋关节置换术（THA）和全膝关节置换术（TKA）的影响尚未得到很好的描述。这项研究的目的是分析PA在4个州的大批量骨科实践中的使用。
方法：我们前瞻性地收集了2020年至2023年在我们机构进行的28,725个主要THA和TKA的数据。收集的数据包括患者人口统计学，付款人批准或拒绝，批准或拒绝的时间，最初否认的次数，对等(P2P)或附录的数量，以及否认的理由。
结果：七千五百二十八例（56.4％）接受THA的患者和8,283例（54％）接受TKA的患者需要PA，平均批准时间为26.3±34.6和33.7±41.5天，分别。在7,528名（4.6％）THA患者中的608名和8,283名（8.9％）TKA患者中的737名要求补遗。在总共312名(4.1%)最初否认的THA患者中，要求50名(0.7%)患者进行P2P，PA程序后，只有27人（0.4％）得到维持。在总共509名（6.1%）TKA患者中，要求55名(0.7%)患者进行P2P，PA程序后，只有26人（0.3％）得到维持。THA组的平均拒绝时间为64.7±83.5，拒绝的最常见原因是临床记录不佳（25.9％）和缺乏覆盖率（25.9％）。TKA组的平均拒绝时间为63.4±103.9天，付款人未指定最常见的拒绝原因(46.1%)。
结论：使用PA批准选择性THA和TKA导致手术等待时间增加，外科医生和医护人员的行政负担很高。
方法：我们前瞻性地收集了2020年至2023年在我们机构进行的28,725个主要THA和TKA的数据。收集的数据包括患者人口统计学，付款人批准或拒绝，批准或拒绝的时间，最初否认的次数，对等(P2P)或附录的数量，以及否认的理由。
结果：七千五百二十八例（56.4％）接受THA的患者和8,283例（54％）接受TKA的患者需要PA，平均批准时间为26.3±34.6和33.7±41.5天，分别。在7,528名（4.6％）THA患者中的608名和8,283名（8.9％）TKA患者中的737名要求补遗。在总共312名(4.1%)最初否认的THA患者中，要求50名(0.7%)患者进行P2P，PA程序后，只有27人（0.4％）得到维持。在总共509名（6.1%）TKA患者中，要求55名(0.7%)患者进行P2P，PA程序后，只有26人（0.3％）得到维持。THA组的平均拒绝时间为64.7±83.5，拒绝的最常见原因是临床记录不佳（25.9％）和缺乏覆盖率（25.9％）。TKA组的平均拒绝时间为63.4±103.9天，付款人未指定最常见的拒绝原因(46.1%)。
结论：使用PA批准选择性THA和TKA导致手术等待时间增加，外科医生和医护人员的行政负担很高。
