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Prior authorization is commonly used by commercial insurance companies as a cost-controlling policy.

However, a study presented at the 2025 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) found that prior authorization was an ineffective cost-saving measure for patients undergoing primary total hip arthroplasty (THA). In addition, the study authors reported lower preoperative functional outcomes scores and significantly longer wait times before surgery when prior authorization was required.

This is the first study to quantify the time and costs associated with obtaining prior authorization in patients undergoing THA.

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“Prior authorization is employed more frequently for various orthopaedic procedures, and it is forcing an added administration burden on healthcare practices,” said Elizabeth Abe, BS, MS4, lead author of the study.

“This not only increases the time to get a patient approved for the procedure, but it ultimately leads to delays in patient care. If insurance denies a patient’s surgery, sometimes the patient will give up and live in pain. Patients may try other nonoperative treatments that eventually fail them, and then the patient is spending more time and money to fail procedures that don’t change the course of their treatment. Many times, they still need a total hip replacement.”

In a 2023 survey by the American Medical Association, 93% of physicians said that the prior authorization process had delayed their patients’ treatments, 78% believed that delays due to prior authorization led their patients to abandon necessary care, and 24% said that delays from prior authorization led to avoidable, serious adverse events. [1]

Study Data

The study presented at the 2025 AAOS Annual Meeting included patients who underwent unilateral primary THA for end-stage hip osteoarthritis (OA) between January 2020 and December 2022 and who were insured by a single, commercial payor.

Patient-reported outcome measures (PROMs) that included the hip dysfunction and OA outcome score for joint replacement (HOOS-JR) and 12-item short form physical component score (SF-12 PCS) were recorded preoperatively and at 6 months postoperatively.

Data recorded that was specific to the prior authorization process included approval or denial status, days to approval or denial, number of denials, number of peer-to-peer (P2P) reviews or addenda required, and denial reasons.

The primary outcome of the study was the cost associated with obtaining prior authorization in patients that underwent primary THA. These costs consisted of:

• Conservative therapies, diagnostic imaging, and office visits required as part of the prior authorization process
• The costs incurred while patients waited to obtain authorization and approval from their initial surgery request to the date of surgery.

Secondary outcomes included time from surgery request date to the date of THA, preoperative PROMs, and postoperative PROMs.

A total of 3922 commercially insured patients were included, 2,840 (72.4%) patients whose insurance required prior authorization before THA and 1,082 (27.6%) patients whose insurance did not require prior authorization.

Study Findings

Patients in the prior authorization cohort were more likely to be younger, male, identify as black, have an increased BMI, and undergo surgery as an inpatient. Patients requiring prior authorization also were more likely to have lower preoperative HOOS-JR scores (48.1 ± 15.5 versus 49.7 ± 14.7) when compared with patients not requiring prior authorization.\

In the prior authorization cohort compared with the non-prior authorization cohort, the findings included:

• Patients were more likely to experience denial on initial request for THA (1.5% versus 0.0%).
• Surgeons were more likely to be required to participate in a P2P review (0.6% versus 0.0%).
• An addendum was more likely to be submitted (9.4% versus 0.0%, P<0.001) as requested when additional documentation was necessary to determine prior authorization approval or denial.
• Patients more frequently experienced any form of denial (4.8% versus 3.0%).
• Patients experienced significantly longer wait times from initial surgery request date to the date of THA (4 ± 37.0 days versus 38.7 ± 36.0 days).
• In the year preceding THA, significantly fewer patients in the prior authorization cohort underwent radiograph imaging (63.8% versus 68.8%).

Obtaining prior authorization was found to increase time to surgery by 2.1 days. A higher preoperative SF-12 PCS score was found to decrease time to surgery by 0.3 days.

“Delaying the Inevitable”

“The prior authorization process and the steps a patient has to go through do not help save costs in the year prior to surgery,” said one of the study authors, Chad A. Krueger, MD, an orthopaedic surgeon with the Rothman Orthopaedic Institute in Philadelphia.

“Patients whose insurance required prior authorization were found to have significantly worse HOOS-JR scores, which is a measure of how badly their hip feels, so their hips felt worse before surgery, and they experienced longer delays in getting to surgery than patients whose insurance did not require prior authorization.

“We are delaying the inevitable and jumping through hoops to get to surgery. Orthopaedic surgeons and patients can use these findings as fuel to try to work with our Congressional members on both sides of the aisle to improve the prior authorization process.”

The study authors noted that P2P reviews, addendums, and changes in surgery designation from inpatient to outpatient may explain the time delay THA patients with prior authorization experienced, and these additional steps may increase the administrative costs associated with maintaining a practice.

In a separate study by Sahni et al, [2] each submission for prior authorization was estimated to cost between $40 and $50 for private payors and between $20 and $30 for surgeons, with each claim taking 4 to 6 weeks on average to process and pay.

That study also found that for private payors, more than 90% of prior authorization submissions were ultimately approved, further questioning the efficiency and cost-efficacy of the prior authorization process.

The researchers of the prior authorization study presented at the AAOS Annual Meeting concluded that the current process actively increases the administrative burden of THA, contributing to delayed access to care with little consideration of evidence-based treatment.

References

1. American Medical Association. 2024 AMA prior authorization  physician survey. Accessed March 13, 2025.
2. Sahni NR, Gupta P, Peterson M, Cutler DM. Active steps to reduce administrative spending associated with financial transactions in US healthcare. Health Aff Sch 2023;1:qxad053.

Source

Abe E, Lizcano JD, Tarabichi S, Parikh N, Krueger CA, Courtney PM. Prior authorization does not reduce costs in patients undergoing primary total hip arthroplasty. Presented at the 2025 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 10-14, 2025, in San Diego, California.