The Prior Authorization Barriers in Orthopedics

It’s a fact that in the current healthcare landscape that the amount of Prior Authorization errors or lack thereof are draining the healthcare industry in finance and resources. When a patient needs a service, and a facility is overrun with orders it can be a very complicated task for a clinic or facility to manage with so many service lines and variables. Payers and Utilization Management companies had made the process and tasks of obtaining timely authorization erroneous. To complicate matters staffing shortages have led to further disruption in the process, reimbursement, timely A/R. There is an immediate need for augmentation and relational software.

In my 20 years in Healthcare, I have seen many changes in financial and operational processes in medical practices and facilities.  Orthopedics is no stranger to the Prior Authorization. I have worked with many Orthopedic Physicians and Surgeons over the years, and they have all expressed the burden on effective patient care due to the many hoops they must jump through in getting needed services approved.  

According to John Heim D.O.

“I think prior authorization is a double-edged sword. As a gate keeping tool, I agree with the concept but unfortunately for those of us that are practicing ethical medicine sometimes we can save the company money by proceeding with surgery or an MRI when we know other treatments or diagnostic studies are not indicated. The frustrating part is when we have to jump through the hoops of ordering treatments and tests that we know aren’t going to help.”

The data also shows it is a systemic issue not unique to just Orthopedics.
According to the American Hospital Association in a 2020 report:

• One 17-hospital system spends $11 million annually just complying with health plan prior authorization requirements.

• A single 355 bed psychiatric facility needs 24 full-time staff to deal with authorizations.

• A large, national system spends $15 million per month in administrative costs associated with managing health plan contracts, including two to three full-time staff that do nothing but monitor plan bulletins for changes to the rules.

• Physicians report that their offices spend on average two business days of the week
dealing with prior authorization requests, with 86% rating the burden level as high or extremely high (See report by AMA)

According to the 2021 survey, 93% of physicians reported care delays associated with prior authorization, and 82% said these requirements can at least sometimes lead to patients abandoning treatment.

According to a recent Press Release from the American Medical Association


“Prior authorization requirements on evidence-based care can have severe consequences that interfere with a healthy, productive workforce, according to new survey results (PDF) issued today by the American Medical Association (AMA).”

Common Orthopedic Services

In Orthopedics there are many services that require Prior Authorization and, in many cases, review of coverage guidelines even once you obtain a Prior Authorization.

Let’s start with Radiology and Diagnostic tests. Many times, the need to order a procedure starts with diagnosing the patient with confirmation of an imaging service such as Xray, MRI or CT among others. When the medical expertise of a qualified physician meets the regulatory guidelines at an insurance payer, it can delay the needed test. For Instance, when a patient needs to have a procedure of the knee it may be necessary to order an MRI if they suspect any abnormalities within the knee joint. This will help them visualize the knee anatomy to determine the potential cause of patients’ pain, inflammation, or weakness, before a potential surgery.

In other instances, with Fracture care, they may need to order a CT for operative planning and in some cases an MRI for certain types of fracture and depending on the age of the patient. This type of imaging is very helpful in evaluating fractures and can provide anatomic detail, showing the physician possible displacement or any joint involvement. With the benefit of two- and three-dimensional images, this can be helpful in diagnosing the patient.

So, when a physician needs to order this test to diagnose and move forward with a much needed surgery they are often held back as the patients insurance requires proof of several weeks of therapy or other conservative treatment only to discover after such therapy or treatment that the procedure is still needed and the only course of treatment is the procedure they wanted nearly a month previously and treatment has been delayed with the patient condition now worsening. This is a highly sore subject among physicians and a reason why even in the current payer provider conflict climate we are in, we need to be extra diligent and improve communication and appeal processes from peer-to-peer reviews for imaging services.

Another type of service that often requires Authorization is Viscosupplement Intra Articular Injections for Osteoarthritis (HCPCS J7326). Prior Authorization will be required by many payers when the patient does not respond to other conservative treatments. Typically, when you begin the authorization process, they will want to know the following:

  • Has the patient been diagnosed with osteoarthritis of the knee based on radiographic evidence?
  • Impairment of functional activity?
  • Previous treatment failed such as Therapy, Steroid Injections and NSAIDS(non-steroidal anti-inflammatory drugs ) for a period of time?

Some payers may not cover this product at all due to their research into effectiveness and cost or may have criteria on frequency to assess effectiveness and medical necessity. It can be daunting but with communication among staff and a proper diligence in understanding insurance coverage we can be effective in getting these approved and paid. In the Instance of insurance not approving or if they feel it is not medically necessary providers can explain to the patient its effectiveness and many pharmacy payers will approve it. This will allow the patient to bring the medication from the Pharmacy to be injected by the physician with CPT©️ Codes 20610 or 20611.

Getting these services approved is essential as in 2021 Orthopedic Practices and Facilities submitted almost $5 billion in viscosupplementation services with expectations for growth in this service in the next few years, according to market research

*Market research

Improve efficiency with Technology solutions

In my experience and expertise as an Orthopedic Business Consultant I aim to educate on the importance of communication and efficiency in the medical practice. Organization and the proper tools are key. For many years now we have been in the age of technological forward solutions for patient care and this is especially true for the Business of Healthcare. Patients need to know they can rely on the experts in healthcare to help them get the services they need and be assured that the Physician staff is their advocate to help them get these services covered.

Utilizing our proven platforms combined with subject matter experts we are reducing the burden of prior authorization for the specialty. This data is imperative for holding payers and others accountable, while optimizing resources and getting patients to treatment sooner. It is true that the increased time and expense needed for Peer to Peer and navigating payer policies is draining to a clinic and facility budget, which is why we now have to adopt technologies that integrate payer rules for prior authorizations, eligibility verification and streamlining of the Prior Authorization workflow.

Recently Authparency was selected by Microsoft for Startups and per Jordan Johnson, Chief Innovation Officer of OncoSpark

“This program serves as the foundational catalyst that is needed to harness confidence and speed in our solution that is imperative for patients and providers as we define less restrictive value based clinical pathways.”

Jordan Johnson, Chief Innovation Officer Oncospark

What Makes Authparency Valuable

Authparency was designed as a patient advocate to reduce denials, redundant tasks, and waste with a:

  • Transparent process and authorization status indicators
  • Facility and network views
  • Precision pathway mapping
  • Custom Alerts based on Expirations and Order changes
  • Internal audit logs
  • Direct EDI submission
  • Relational documentation mapping and financial integration
One ecosystem to optimize efficiency and accuracy

Additional features include:

  • Insurance discovery, validation, and verification
  • Medical and drug benefits
  • Interfaces with over 50 EHR and PM Systems
  • Payer Policy discovery
  • HUB enrollment
  • Appeals
  • Clinical and financial benchmarking
  • Priority Pathways

Results Matter

When adopting technology, we need to know how it will affect our practice and we want results. For the practices that have adopted this amazing tool 30% saw an increase in resource optimization with standardization and transparency and 23% saw an increase in collections by alerting to expiring authorizations and disease to treatment policy conflicts. There was also a 25% reduction on barriers to procedure access due to integrated enrollment and discovery.

Contact Jmcnamara@oncospark to set up a demo or visit

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