In my 20 years in healthcare, I have seen numerous changes in financial and operational processes. None has been more disruptive than the increase in the requirement for prior authorization.
When a patient needs a service and a facility is overrun with orders from multiple service lines, it can be challenging for staff to manage the Prior Authorization (PA) process adequately.
Payers and utilization management companies have made obtaining timely authorizations onerous. Staffing shortages in healthcare have led to further challenges in successfully handling the prior auth process.
Orthopedics is no stranger to the Prior Authorization. I have worked with many Orthopedic Physicians and Surgeons over the years. They have all expressed concerns about the challenges of delivering effective patient care due to the many hoops they must jump through to get needed services approved.
According to John Heim, D.O.
“I think prior authorization is a double-edged sword. As a gatekeeping tool, I agree with the concept. But unfortunately, for those of us 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 shows that strictly adhering to prior authorization protocols is a systemic issue and not unique to 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 could at least sometimes lead to patients abandoning treatment.
And a recent Press Release from the American Medical Association stated
“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, numerous services require Prior Authorization and, in many cases, a review of coverage guidelines, even after 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 of an insurance payer, it can delay the required test. For instance, when a patient needs to have a procedure on the knee, it may be necessary to order an MRI if the doctor suspects any abnormalities within the knee joint.
The MRI image will help them visualize the knee anatomy to determine the potential cause of patients’ pain, inflammation, or weakness, before a possible surgery.
In other instances, with fracture care, the physician may need to order a CT scan for operative planning and, in some cases, an MRI for certain types of fracture, depending on the patient’s age. This imaging helps evaluate fractures and provides anatomic detail, showing the physician a possible displacement or joint involvement. Having two-and three-dimensional images can help diagnose the patient.
So, when a physician needs to order these tests to diagnose and move forward with a needed surgery, they are often held back because the patient’s insurance requires proof of several weeks of therapy or other conservative treatment—only to discover the procedure is still needed. The result is the required treatment has been delayed by weeks, and the patient’s condition has worsened.
These circumstances are a sore subject among physicians and a reason why even in the current climate of payer-provider conflict, we need to be extra diligent and improve communication and the appeal process 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). Many payers will require prior authorization 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?
- Is their impairment of functional activity?
- Previous treatment failed such as physical therapy, steroid injections and NSAIDS(non-steroidal anti-inflammatory drugs ) for a period of time?
Some payers may not cover this product due to their research into its effectiveness and cost or may have criteria on frequency to assess the efficacy and medical necessity.
It can be daunting, but with communication among staff and 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.
Improve Efficiency with Technology Solutions
In my experience and expertise as an Orthopedic Business Consultant, I aim to educate professionals on the importance of communication and efficiency in medical practices. Organization and utilizing the proper tools are critical.
For many years we have been in the age of technology-forward solutions for patient care. This is especially true for the healthcare. Patients need to know they can rely on healthcare experts to help them get the services they need—and be assured that the physician staff is their advocate to help them get these services.
By utilizing our proven platforms combined with subject matter experts, we reduce the burden of prior authorization for orthopedics and other specialties.
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.”
What Makes AuthParency Valuable
AuthParency was designed as a patient advocate to reduce denials, redundant tasks, and waste. It provides:
- A transparent process
- 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
AuthParency provides one ecosystem to optimize efficiency and accuracy
Additional features include:
- Insurance discovery, validation, and verification
- Medical and drug benefits
- Compatible with all EHR and Practice Management (PM) systems
- Payer Policy discovery
- HUB enrollment
- Appeal tools
- Clinical and financial benchmarking
- Priority Pathways
Schedule a call today to learn how we can help you to solve your prior authorization issues.