Resident perspectives on prior authorization: The “hidden curriculum” underlying the administrative burden

Orthopaedic surgery residents often experience firsthand the complexities of our healthcare landscape, where clinical decision making intersects with administrative hurdles. Among the modern barriers to delivering patient care, prior authorization (PA) represents a burdensome and often opaque process that can delay or prevent necessary treatment.

Intended to ensure cost-effective care and prevent unnecessary utilization, PA is the process by which insurers, whether commercial or government (Medicare/Medicaid), require approval before covering services such as imaging, medications, durable medical equipment (DME), or elective procedures. Following submission of the PA request, payers will often request additional documentation or peer-to-peer reviews, or they may simply deny the request. Studies of PA in the Medicare Advantage population showed that, although most denials are ultimately overturned, the process is often time intensive. Depending on the pathology, such a delay could be catastrophic.

Accordingly, AAOS has made PA reform a central advocacy priority, pursuing change through both legislative and regulatory initiatives. Residents should be familiar with the key initiatives currently in play. The Improving Seniors’ Timely Access to Care Act is one such initiative, seeking to modernize and streamline the PA process for Medicare Advantage plans. This legislation would codify regulatory changes by the Centers for Medicare & Medicaid Services (CMS) to require certain payers to respond to expedited PA requests within 72 hours and standard requests within seven days, using electronic medical records.

AAOS also supports legislation in which physicians who obtain approval for at least 90% of their PA requests are exempted from PA processes for a specific payer. This concept, commonly known as a “gold card” for such physicians, has proven effective, as demonstrated by commercial payer pilot initiatives and phased implementation programs and has been codified in several state legislatures. Be sure to visit the AAOS Advocacy Action Center to stay up to date on current issues and contact your legislator to express your support for these initiatives.

Meaningful legislative and regulatory reform takes time. In addition to advocating for system reform, residents can mitigate the burdens associated with PA by learning more about it and sharing their knowledge with their patients.

Unlike billing and coding, which are discussed (albeit minimally) in resident didactics, PA is opaque to many residents. Despite its ubiquity, PA is rarely, if ever, formally discussed and remains a part of the “hidden curriculum” of residency training. Furthermore, in most practice environments, PA processes are primarily managed by nonphysician clinic staff. While more efficient from an operational standpoint, this effectively insulates residents from PA procedures and means that a resident may train for five years without ever participating in a PA process.

To bridge that knowledge gap, residents should advocate for discussing these topics with attending surgeons and clinic staff and, where possible, participate in a PA process. Residents should seek to understand which interventions and procedures in their subspecialty are most at risk of denial. Also, residents should seek to understand how clinical documentation interacts with the PA process and build habits to promote proactive communication and documentation. Just as residents discuss surgical indications, they also ought to discuss how documentation clarity supports timely care. Finally, when the opportunity arises, ask to listen in or even lead a peer-to-peer discussion. To better understand the nuances of PA is to better understand the barriers to patient care.

Similarly, residents can advocate for their patients when PA-related issues arise. With a thorough understanding of the administrative and bureaucratic underpinnings of the PA process, residents can effectively counsel patients and thereby reduce confusion and distress. Also, residents with practical experience can better navigate situations in which a patient’s clinical urgency requires timely intervention outside of the PA request.

Consider the example of a patient with progressive myelopathic symptoms or a worsening neurologic deficit while awaiting PA approval for MRI imaging. This patient needs escalation: either immediate imaging authorization or an emergency department referral. Determining the threshold at which such patients should be referred to the emergency department for urgent evaluation and imaging is a complex clinical skill. Such clinical situations, and the variations of which that exist for each subspecialty, should be deliberately discussed with faculty mentors.

Orthopaedic residents should not be bystanders in the PA process. Residents should enhance their education by seeking opportunities to better understand the PA process and how their documentation affects it. Participating in peer-to-peer reviews and understanding ways in which care can be expedited for urgent issues prepares residents to be future advocates for their patients. Residents should advocate for system reform, stay informed, and write to elected officials to show support for relevant legislative and regulatory initiatives.

While prior authorization may be one of the many components of the “hidden curriculum” in orthopaedic surgery education, shining a light on it will enable residents to help move the needle for patients and the profession.

Jack Ayres, MD, is a third-year orthopaedic surgery resident at Prisma Health/University of South Carolina School of Medicine–Columbia in South Carolina and served on the AAOS Resident Assembly Health Policy Committee.

George Sayegh, BS, is a medical student at The University of Texas Health Science Center at San Antonio and serves on the AAOS Resident Assembly Health Policy Committee. His academic interests include health policy, alternative care delivery models, and the role of emerging innovations in orthopaedics.