Physicians have long ranked prior authorization among the most maddening parts of practicing medicine, and UnitedHealthcare recently pledged to cut its prior authorization requirements by 30%. But one spine surgeon said the cut leaves the most significant bottleneck completely untouched.
Justin Iorio, MD, an orthopedic spine surgeon at Syracuse, N.Y.-based St. Joseph’s Physicians Orthopedics, said trimming the volume of procedures subject to prior authorization does little to change the dollar amount tied up in the process. Until insurers address the cost concentration driving denials on the most expensive procedures, he said, incremental cuts to prior authorization volume will keep producing headlines without changing the numbers that matter to physicians and patients.
That is because prior authorization spend follows something close to an 80-20 distribution: A small share of high-cost procedures accounts for most of the money insurers are scrutinizing.
“If you reduce prior authorizations by 30%, that does not mean there’s a 30% reduction in the amount of money that requires prior authorization,” he said.
Dr. Iorio said the UnitedHealthcare cuts just remove the “low-hanging fruit” — routine medications and imaging that already get approved within about 24 hours roughly 98% of the time — while leaving the expensive procedures untouched. In his practice, that means lumbar and cervical spine fusions and total joint replacements, which he said face high denial rates because of implant and reimbursement costs, not because they are inappropriate care.
“Those are the procedures that really need to be looked at and better understood for prior authorization, and that’s not what this is doing,” he said.
Dr. Iorio said a lack of up-front reviews on procedures also raises questions. He said it could shift risk to retroactive denial rather than eliminating it.
“What they’re saying is, ‘Go ahead, do what you want to do. We’ll let you know if we’re going to pay for it later,'” he said.
The administrative cost of managing this process is substantial. His five-surgeon practice needed more than one full-time staffer dedicated to prior authorization, on top of the delays in scheduling and starting treatment.
Dr. Iorio said that burden falls hardest on independent practices, which do not have the scale or in-house infrastructure to absorb it the way hospitals and health systems can. He spent nine years in private practice before moving to a hospital-employed role last year, and said his former group — a sizable, high-volume practice by national standards — ultimately sold to a private equity firm because the administrative and reimbursement pressures made it unsustainable to stay independent.
What could move the needle
Dr. Iorio pointed to two changes he believes would address the underlying problem rather than trim around its edges.
The first is broader adoption of physician “gold card” programs, which exempt physicians with strong track records of approved, medically appropriate care from prior authorization requirements for specific services. Several states have passed gold-card laws in recent years, though adoption and scope vary widely by insurer and state.
The second is shifting who writes the clinical criteria insurers use to approve or deny procedures. He pointed to California as a rare example where prior authorization standards are developed by physician groups rather than insurance company medical directors, and argued that model should be more widely adopted — with recommendations coming from specialty societies, such as spine surgery associations, rather than insurer-specific policies that vary by company and even by plan within the same company.
He offered a personal example: a request to perform a disc replacement alongside a spinal fusion, a technique he said is supported by numerous published studies despite lacking a specific FDA approval for that exact combination. The claim was denied — twice, including on appeal — because it fell outside the insurer’s written policy guidelines, not because the clinical evidence was lacking.
“There’s no society or group of surgeons that comes up with recommendations that insurance companies at large follow,” he said. “Instead, you have one company saying you can only use this device, and another company saying you can do this procedure but only if you also do that one.” He said the inconsistency between insurers’ criteria, sometimes down to which specific implant or device is permitted, makes it difficult to know in advance which cases will be approved and which will require an appeal.
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