Prior Authorization Does Not Reduce THA Costs, Leads to Delays in Patient Care

Commercial insurance companies often use prior authorization as an attempt to control costs. However, a study presented at the AAOS 2025 Annual Meeting found that prior authorization was an ineffective cost-saving measure for patients undergoing primary total hip arthroplasty (THA). The study, titled “Prior Authorization Does Not Reduce Costs in Patients Undergoing Primary Total Hip Arthroplasty,” also found that prior authorization was associated with lower preoperative function scores and significantly longer wait times before surgery. It is the first study to quantify the time and costs associated with obtaining prior authorization in patients undergoing THA.

“Prior authorization is employed more frequently for various orthopaedic procedures, and it is forcing an added administrative burden on healthcare practices,” said Elizabeth Abe, BS, 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.”

The study included patients who underwent unilateral, primary THA for end-stage hip osteoarthritis (OA) from January 2020 through December 2022 and were insured by a single commercial payer. Patient-reported outcome measures (PROMs), including the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and 12-Item Short Form Survey Physical Component Score (SF-12 PCS), were recorded preoperatively and at 6 months postoperatively. Data 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 who underwent primary THA. Costs consisted of:

• conservative therapies, diagnostic imaging, and office visits required as part of the prior authorization process
• 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 3,922 commercially insured patients were included, including 2,840 (72.4 percent) patients whose insurance required prior authorization before THA and 1,082 (27.6 percent) patients whose insurance did not require prior authorization. Patients in the prior authorization cohort were more likely to be younger and 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 to the non-prior authorization cohort, the findings included:

• Patients were more likely to experience denial on initial request for THA (1.5 percent versus 0.0 percent).
• Surgeons were more likely to be required to participate in a P2P review (0.6 percent versus 0.0 percent).
• An addendum was more likely to be submitted (9.4 percent versus 0.0 percent, 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 percent versus 3.0 percent).
• Patients experienced significantly longer wait times from initial surgery request date to the date of THA (40.4 ± 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 percent versus 68.8 percent).

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.

“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 coauthor Chad A. Krueger, MD, FAAOS, an orthopaedic surgeon at Rothman Orthopaedics 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 the time delay THA patients with prior authorization experienced may be explained by the requirement of P2P reviews and addenda and changes in surgery designation from inpatient to outpatient. These additional steps may increase the administrative costs associated with maintaining a practice.

The authors 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 or when various therapies would be most beneficial to patients.

Ms. Abe and Dr. Kreuger’s coauthors of “Prior Authorization Does Not Reduce Costs in Patients Undergoing Primary THA” are Juan D. Lizcano, MD; Nihir Parikh, BS; Paul M. Courtney, MD, FAAOS; and Saad Tarabichi, MD.