Physicians have been clear that prior authorization delays and denials remain one of the most persistent operational headaches in practice. That headache, surgeons say, drags out surgical scheduling, adds administrative burden and, in some cases, drives patients out of treatment altogether.
Here are five approaches surgeons told Becker’s are moving the needle in addressing the issue:
1. Front-load documentation to match payer guidelines exactly
Several surgeons have said the most effective fix happens before a request is ever submitted. Robert Tatsumi, MD, president of Oregon Spine Care in Tualatin, said he has found that commercial payers tend to apply similar clinical guidelines for surgical indications. His practice builds EMR templates that explicitly document how a patient meets those guidelines before a prior authorization request goes out — a step he credits with meaningfully limiting denials in the first place.
2. Treat the peer-to-peer call as a formality, not a fight
When a denial does come through, Dr. Tatsumi requests a peer-to-peer review — and said the outcome is often decided before the call even starts. In his experience, the reviewing physician frequently overturns the denial simply after reading the clinical note, making the actual phone conversation something of a formality.
3. Triage by clinical urgency when delays are unavoidable
Not every delay can be prevented. Ronald Gardner, MD, founder of Gardner Orthopedics in Fort Myers, Fla., said his practice manages unavoidable prior authorization delays by prioritizing surgical scheduling according to acuity of need, pushing the most urgent cases through first rather than treating every delayed case the same way.
4. Get ahead of the conversation with patients
Multiple surgeons pointed to patient communication as an underrated mitigation strategy. Madhish Patel, DO, orthopedic surgeon at Gardner Orthopedics in Fort Myers, Fla., said counseling patients about the possibility of a prior authorization delay before it happens, rather than after, has been shown to improve patient satisfaction scores and reduce the stress patients experience navigating the process.
5. Push back on the system itself
Not every workaround is procedural. Some surgeons have said the system needs to change. One orthopedic surgeon has called for the removal of prior authorization “red tape,” arguing that a more standardized communication system between practices and payers could cut down on unnecessary denials. That critique has some research behind it: A study found that prior authorization does not actually reduce orthopedic-related costs, undercutting one of insurers’ core justifications for the process.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
