The current prior authorization system in orthopedics leads to unnecessary denials and delays that could be improved with a level of standardization, according to this orthopedic surgeon.
A new communication system for prior authorizations could allow for insurance companies to inform surgeons and patients what is still needed in real-time, which would lessen the chance for same-day cancellations.
Surgeons are always planning and assuming that surgeries will be approved because they are completing their due diligence, but the red tape from insurance companies can sometimes hold them up.
Brian Nwannunu, MD, an orthopedic surgeon at the Texas Joint Institute in Dallas, recently connected with Becker’s to talk about some potential changes to improve the system.
Note: Responses were lightly edited for clarity and length.
Question: What is something that is being overlooked or not getting enough coverage in the orthopedic conversation today?
Dr. Brian Nwannunu: The hurdles that insurance companies are putting patients and clinicians through. We have these prior authorizations that we must attain before surgery. Insurance companies are telling us as doctors that these patients aren’t candidates for surgery for whatever reason, because it’s not checking some box. This patient that’s been in pain forever or had an injury, that’s failed all these conservative management approaches and who are ready for surgery, are now being denied because of insurance reasons.
Different insurance companies have different criteria, and I don’t believe any of them come from a clinician’s standpoint. It’s all kind of red tape. I just don’t think it’s talked about enough on a granular level, about how insurance companies are able to do that and why patients are suffering from it. I personally have had to cancel a surgery the day of because it didn’t get prior authorization. That morning, I had to call the insurance company while the patient was waiting for surgery and advocate for this patient just to get that surgery put back on. That’s just not a good use of our system.
Q: If you could bypass all the legislative hurdles and implement a fix tomorrow, what would that be?
BN: A standardized communication system that would allow us to say, this patient is going for surgery for these reasons. Is there any reason they shouldn’t go? That would be much better than signing them up, putting in this authorization and waiting days to hear back from the insurance companies. We always hope that it will proceed, because we did our due diligence. We’re still making informed decisions that we feel are the best for our patients. So we are assuming it’s going to proceed, because there’s so many moving parts and we can’t just wait for the authorization.
An analogy I like to use is planning a vacation. You’ve booked your tickets and hotel, you’ve taken time off from work, you’ve bought your luggage. Then, when you show up to the airport on the morning of the trip, you’re told that the airline ticket wasn’t approved. That’s very frustrating, because for whatever reason, the airline process of approval is separate from when you put in the purchase of the ticket. If that happened in the airline industry, they would go bankrupt.
