Prior Authorization in Total Joint Arthroplasty: Evaluating the Impact on Patient Care

Abstract

Background Prior authorization (PA) in total joint arthroplasty (TJA) can challenge patients and providers. This study examines how site-of-care decisions impact outcomes by comparing patients approved for inpatient vs outpatient surgery, with the goal of improving PA processes and guiding best practices. Methods PA data from primary TJA (n = 1030) cases were retrospectively collected at a tertiary academic center from June to December 2022. Variables included demographics, comorbidities, American Society of Anesthesiologists (ASA) score, insurance type, submission method, and site-of-care request. Cohorts were analyzed by site-of-care determination, time to decision, length of stay, and complications. Statistical analysis used Chi-square and t-tests. Results PA was required for 81% (n = 736) of inpatient TJA cases, with a 90% (n = 661) approval rate. Approved inpatient cases were associated with older age (64.3 ± 10, P = .04), women (n = 464, 74%, P < .01), ASA class 3-4 (n = 334, 53%, P < .01), and higher body mass index (33.2 ± 6.7 kg/m2, P < .01). Thirty percent of requests used noninternet methods, with Managed Medicare patients accounting for 53% (n = 343). Median time to decision was 4 days (range 0-37). Only 30% of patients denied inpatient admission achieved same-day discharge. No significant differences in postoperative complications were observed. Conclusions PA significantly influences TJA patients and providers, with most cases requiring PA. Approval was influenced by site-of-care request, age, sex, health status, and insurance type. Frequent noninternet submissions and prolonged decision times identify areas for improvement overall.