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Jarrett CD, Dawes A, Abdelshahed M, Cil A, Denard P, Port J, Weinstein D, Wright MA, Bushnell BD. The impact of prior authorization review on orthopaedic subspecialty care: a prospective multicenter analysis. J Shoulder Elbow Surg 2024; 33:e336-e342. [PMID: 37993089 DOI: 10.1016/j.jse.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/21/2023] [Accepted: 10/18/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Prior authorization review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on health care has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care. METHODS A prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from 6 states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker's compensation, or government payor [ie, Tricare, Veterans Affairs]), location of service, rate of approval or denial, time to approval or denial, and administrative time required to complete process were all recorded and evaluated. RESULTS Of 1065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker's compensation, or governmental insurance (P < .001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker's compensation, and Medicaid required approximately 3-4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (P < .001). After controlling for the payor, we identified a significant difference in approval or denial based on geographic location (P < .001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request. CONCLUSIONS This is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource use and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As health care shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.
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Affiliation(s)
- Claudius D Jarrett
- Wilmington Health Orthopaedics and Sports Medicine, Wilmington, NC, USA.
| | | | | | - Akin Cil
- Department of Orthopaedic Surgery, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | - Patrick Denard
- Oregon Shoulder Institute, Southern Oregon Orthopedics, Medford, OR, USA
| | - Joshua Port
- Altoona Curve AA Baseball, University of Pittsburgh Medical School, Altoona, PA, USA
| | - David Weinstein
- Colorado Center for Orthopaedic Excellence, Colorado Springs, CO, USA
| | - Melissa A Wright
- MedStar Union Memorial Hospital/MedStar Orthopedic Institute, Division of Shoulder & Elbow Surgery, Baltimore, MD, USA; Department of Orthopedic Surgery, Georgetown University School of Medicine, Washington, DC, USA
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Imam N, Zaifman JM, Bassora R, Cherian C, Kohan EM, Alberta FG, Koerner JD. Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved. Orthopedics 2024; 47:141-146. [PMID: 37921528 DOI: 10.3928/01477447-20231027-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
In the event of prior authorization denial, physicians may request peer-to-peer review, which may delay treatment and increase administrative burden. The purpose of this study was to quantify the approval rate of peer-to-peer review and evaluate its efficiency in the context of advanced imaging use in an orthopedic practice. Patients at a single outpatient orthopedic clinic initially receiving an insurance denial for computed tomography or magnetic resonance imaging requiring peer-to-peer review from March to December 2022 were prospectively enrolled. Characteristics of the request, peer-to-peer review, and the reviewer and dates in the process were collected. If the study was approved after peer-to-peer review, the date of the imaging study and brief results were recorded. A total of 62 denials were included. One denial was approved prior to peer-to-peer review. Fifty-eight (of 61, 95.1%) reviews were approved, of which 51 (of 58, 87.9%) studies were completed by patients. Reviewers were always physicians (61 of 61, 100%), but of those whose specialty was known, none were orthopedic surgeons. Forty-four of 61 (72.1%) reviewers reported reviewing clinical notes in advance. The median number of days from visit to peer-to-peer review was 9.0 (interquartile range, 7.0-13.25). The median number of days from visit to imaging center appointment was 13.5 (interquartile range, 9.0-20.75) for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis. In an orthopedic specialty practice, almost all peer-to-peer reviews were approved, with the majority of the completed studies confirming the suspected diagnosis. Thus, patient care was delayed. Reform is crucial to improve the efficiency of the review process, especially in light of additional administrative and financial burden. [Orthopedics. 2024;47(3):141-146.].
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Harish KB, Chervonski E, Speranza G, Maldonado TS, Garg K, Sadek M, Rockman CB, Jacobowitz GR, Berland TL. Prior authorization requirements in the office-based laboratory setting are administratively inefficient and threaten timeliness of care. J Vasc Surg 2024; 79:1195-1203. [PMID: 38135169 DOI: 10.1016/j.jvs.2023.10.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/12/2023] [Accepted: 10/30/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the administrative and clinical impacts of prior authorization (PA) processes in the office-based laboratory (OBL) setting. METHODS This single-institution, retrospective analysis studied all OBL PAs pursued between January 2018 and March 2022. Case, PA, and coding information was obtained from the practice's scheduling database. RESULTS Over the study period, 1854 OBL cases were scheduled; 8% (n = 146) required PA. Of these, 75% (n = 110) were for lower extremity arterial interventions, 19% (n = 27) were for deep venous interventions, and 6% (n = 9) were for other interventions. Of 146 PAs, 19% (n = 27) were initially denied but 74.1% (n = 7) of these were overturned on appeal. Deep venous procedures were initially denied, at 43.8% (n = 14), more often than were arterial procedures, at 11.8% (n = 13). Of 146 requested procedures, 4% (n = 6) were delayed due to pending PA determination by a mean 14.2 ± 18.3 working days. An additional 6% (n = 8) of procedures were performed in the interest of time before final determination. Of the seven terminally denied procedures, 57% (n = 4) were performed at cost to the practice based on clinical judgment. CONCLUSIONS Using PA appeals mechanisms, while administratively onerous, resulted in the overturning of most initial denials.
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Affiliation(s)
| | | | | | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Caron B Rockman
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Todd L Berland
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
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Lizcano JD, Goh GS, Tarabichi S, Krueger CA, Austin MS, Courtney PM. Prior Authorization Leads to Administrative Burden and Delays in Treatment in Primary Total Joint Arthroplasty Patients. J Arthroplasty 2024:S0883-5403(24)00229-8. [PMID: 38493967 DOI: 10.1016/j.arth.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024] Open
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.
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Affiliation(s)
- Juan D Lizcano
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Graham S Goh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Saad Tarabichi
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Matthew S Austin
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Paul M Courtney
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Sahni NR, Gupta P, Peterson M, Cutler DM. Active steps to reduce administrative spending associated with financial transactions in US health care. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad053. [PMID: 38756977 PMCID: PMC10986268 DOI: 10.1093/haschl/qxad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 05/18/2024]
Abstract
US health care administrative spending is approximately $1 trillion annually. A major operational area is the financial transactions ecosystem, which has approximately $200 billion in spending annually. Efficient financial transactions ecosystems from other industries and countries exhibit 2 features: immediate payment assurance and high use of automation throughout the process. The current system has an average transaction cost of $12 to $19 per claim across private payers and providers for more than 9 billion claims per year; each claim on average takes 4 to 6 weeks to process and pay. For simple claims, the transaction cost is $7 to $10 across private payers and providers; for complex claims, $35 to $40. Prior authorization on approximately 5000 codes has an average cost of $40 to $50 per submission for private payers and $20 to $30 for providers. Interventions aligned with a more efficient financial transactions ecosystem could reduce spending by $40 billion to $60 billion; approximately half is at the organizational level (scaling interventions being implemented by leading private payers and providers) and half at the industry level (adopting a centralized automated claims clearinghouse, standardizing medical policies for a subset of prior authorizations, and standardizing physician licensure for a national provider directory).
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Affiliation(s)
- Nikhil R Sahni
- Department of Economics, Harvard University, Cambridge, MA 02138, United States
- Center for US Healthcare Improvement, McKinsey & Company, Boston, MA 02210, United States
| | - Pranay Gupta
- Center for US Healthcare Improvement, McKinsey & Company, Boston, MA 02210, United States
| | - Michael Peterson
- Center for US Healthcare Improvement, McKinsey & Company, Boston, MA 02210, United States
| | - David M Cutler
- Department of Economics, Harvard University, Cambridge, MA 02138, United States
- National Bureau of Economic Research, Cambridge, MA 02138, United States
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Diane A, Gencarelli P, Lee JM, Mittal R. Utilizing ChatGPT to Streamline the Generation of Prior Authorization Letters and Enhance Clerical Workflow in Orthopedic Surgery Practice: A Case Report. Cureus 2023; 15:e49680. [PMID: 38161881 PMCID: PMC10756745 DOI: 10.7759/cureus.49680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Prior authorization is a cumbersome process that requires clinicians to create an individualized letter that includes detailed information about the patient's medical condition, proposed treatment plan, and any supplemental information required to obtain approval from a patient's insurance company before any services or procedures may be provided to the patient. However, drafting authorization letters is time-consuming clerical work that not only places an increased administrative burden on orthopedic surgeons and office staff but also concurrently takes time away from patient care. Therefore, there is a need to improve this process by streamlining workflows for healthcare providers in order to prioritize direct patient care. In this report, we present a case utilizing OpenAI's ChatGPT (OpenAI, L.L.C., San Francisco, CA, USA) to draft a prior authorization request letter for the use of matrix-induced autologous chondrocyte implantation to treat a cartilage injury of the knee.
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Affiliation(s)
- Alioune Diane
- Department of Orthopaedic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Pasquale Gencarelli
- Department of Orthopaedic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - James M Lee
- Department of Orthopaedic Surgery, Orange Orthopaedic Associates, West Orange, USA
| | - Rahul Mittal
- Department of Health Informatics, Rutgers School of Health Professions, Newark, USA
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