Prior Authorization in Primary Total Hip Arthroplasty: Delays Without Financial Gains.

Abstract

Prior authorization (PA) has been implemented by payers to reduce unnecessary healthcare utilization. However, obtaining PA has been shown to increase the administrative burden and delay access to care. To our knowledge, the financial burden and cost-effectiveness of PA in total hip arthroplasty (THA) are yet to be determined. The purpose of this prospective study was to quantify the costs associated with obtaining PA in primary THA patients. A matched series of 1,788 patients undergoing primary THA with a single, commercial insurance payer from 2020 to 2022 at our institution was included. Data on PA status, number of services utilized, and total claims cost of nonoperative treatment received in the year before THA and incurred from the initial surgery request date to date of surgery were prospectively collected and analyzed. When comparing matched cohorts, no difference was found to exist among mean claims costs in the year before THA ($308 ± 220 in PA Required versus $316 ± 264 in the No PA cohort, standard mean difference [SMD) = 0.032) and incurred from initial surgery request date to date of THA ($295 ± 200 in PA Required versus $305 ± 249 in the No PA cohort, SMD =0.041). However, patients who required PA experienced a significantly longer duration from the initial surgery request date to the date of THA (43 ± 39 versus 39 days ± 37, SMD = 0.083). In the present study, obtaining PA was found to be an ineffective cost-saving measure in patients undergoing primary THA. Additionally, THA patients who required PA experienced significantly longer wait times before undergoing THA.