Prior authorization delays and standardized codes that do not measure case variability are just two orthopedic policy disconnects surgeons say they face on a day-to-day basis.
While insurance companies intend for prior authorization to act as a guardrail, some leaders say it often creates even more of a burden and strain on physicians, patients and administrative staff.
Four surgeons and leaders connected with Becker’s to discuss the areas of practice that are not properly captured by the policies of insurance companies and hospitals.
Ask Orthopedic Surgeons is a weekly series of questions posed to orthopedic surgeons and leaders around the country about clinical, business and policy issues affecting orthopedic care.
Becker’s invites all orthopedic surgeons and specialists to respond.
Next question: What external pressure(s) in the orthopedic industry concerns you most today?
Please send responses to Cameron Cortigiano at ccortigiano@beckershealthcare.com by 5 p.m. Central time on Feb. 23.
Editor’s note: This response has been lightly edited for clarity and length.
Question: Where do you see the biggest disconnect between orthopedic policy decisions and day-to-day clinical reality?
Adam Bitterman, DO. Chair of the Department of Orthopaedic Surgery at Huntington (N.Y.) Hospital: One of the biggest disconnects between orthopedic policy decisions and day-to-day clinical reality is that policy is built around measurable metrics, while orthopedic care depends on nuanced clinical judgment. On paper, procedures can appear standardized: a hip fracture or ankle fracture is assigned a code, a benchmark length of stay and an expected complication rate. In practice, however, every patient brings a different physiologic reserve, medical history, and social support structure. Two patients with the same diagnosis may require very different approaches. Policies grounded in averages often struggle to capture that variability.
Cassandra Lee, MD. Orthopedic Surgeon and Chief of Sports Medicine of University of California at Davis Health (Sacramento): The time required to take care of patients doesn’t match the productivity metric. Say you come in with knee injury, when I actually start seeing you, first clinic visit to get your history, examine you, look at imaging and come up with a plan. Sounds easy, but wait, I’m a specialist, so I have to get your images uploaded into my system so that I can view them, half the time patient doesn’t bring their images (because they were told it was sent), the other half it supposedly accessible by a share agreement, but they still can be seen. I then have to document what we talked about, your exam, our plan, rationalization, risks and benefits. My back office then has to get authorization; sometimes it is just uploading paperwork, sometimes it requires a discussion, sometimes they get lost in phone trees.
And then there’s denials, where I get pulled back into this. Insurance companies are now dividing the authorization procedure with some insurance taking group A codes, and then the third party taking group B codes. Mind you, group B codes sometimes don’t make sense without group A codes (i.e., they should be coupled), so insurance denies because the third party makes a determination on these group B codes that aren’t meant to stand alone.
Then comes the peer-to-peer game, when the insurance doctor is available at a certain time, so either I can call at that time, or they can call me, with a time deadline. Some actually call on days we didn’t agree upon, but that’s another story. This is all before we go to surgery and is invisible to policy models.
Another major disconnect is the emphasis of quality metrics that are not what matters most. I believe the hospital looks at infection rate, readmissions and length of stay. My patients and I are more concerned with return of function, return to sport, return to work and durability of surgical intervention.
The other thing I grapple with is how systems equate lower immediate costs with value. This is short sighted because orthopedic outcomes take years to develop whereas budgets are immediate. The cost may be higher initially with an earlier procedural intervention (i.e. surgical), or getting advanced imaging or using a higher-cost implant. But if it restores function, guides earlier return to work/sport/productivity, or preserves longevity and functionality, short-term savings come at the expense of long-term function.
Michael Russell, MD. Orthopedic Spine Surgeon and Past Chairman of OrthoLoneStar (Houston): Spine surgery has historically been an inpatient practice. While advances in technique and perioperative care have allowed earlier discharges, many patients still require more than two nights in the hospital for safety, pain management, drain monitoring and physical therapy. In today’s environment, insurance companies are increasingly approving spine surgeries as outpatient procedures, even when medical necessity clearly supports an inpatient stay. In many cases, these procedures are approved only as outpatient despite appearing on the inpatient-only list. When this is challenged, we are told that commercial plans do not follow the inpatient-only list and that it applies solely to Medicare. However, after the surgery is performed and the patient appropriately remains inpatient, the claim is denied — often citing the inpatient-only list. The hospital then rebills the claim as inpatient, only to face another denial for lack of prior inpatient authorization. This contradictory and circular process creates a significant administrative burden for office staff, exposes patients and hospitals to unnecessary financial risk, and undermines physician clinical judgment. Ultimately, these policies shift cost and responsibility away from insurers while placing strain on providers and the patients they serve, which is infuriating.
Alex Vaccaro, MD, PhD. President and Spine Surgeon of Rothman Orthopaedics (Philadelphia): In my opinion, the biggest disconnect between orthopedic policy and day-to-day clinical reality is prior authorization. What was supposed to act as an administrative guardrail has evolved into a significant barrier to care. Prior authorization has seemingly prioritized standardized rules and checklists over personalized care and patient-centered decision-making.
Many insurance companies demand a rigid care pathway that forces patients with spinal complaints through an organized physical therapy program which can be very expensive, followed by injections, before surgical interventions are even considered. The policy assumption is that conservative treatment is always the safest starting point. The clinical reality in spine surgery is that one size does not fit all.
In patients with progressive cervical myelopathy, delaying decompression to mandate physical therapy risks irreversible spinal cord injury. For patients with severe lumbar stenosis and recurrent falls, mandated step therapy can convert a manageable condition into progressive functional decline and loss of independence. By the time surgery is approved, patients are more likely to decondition and consequently less likely to recover quickly, which may increase both surgical risk and cost.
When a case does not fit predefined boxes, surgeons are forced into peer-to-peer reviews, increasingly conducted by non-spine physicians. This creates a professional mismatch in which fellowship-trained spine surgeons must justify urgency to reviewers who have never met the patient nor performed a spine surgery.
Patients waiting for approval frequently present to emergency departments for uncontrolled pain. Delays in definitive care also drive prolonged opioid use in spine patients, increasing the risk of dependency. Many patients with spine pathology are pushed into short-term disability while awaiting approval.
In spine care, prior authorization does not safeguard practice patterns, it directs them. When standardized pathways override clinical judgment, surgeons are forced to make recommendations that are not always patient-centered. If policy is to align with the realities of spine surgery, prior authorization must evolve to recognize neurologic urgency, exam-based decision-making and ensure that complex spine cases are reviewed by appropriate subspecialists. Until then, it will remain one of the clearest examples of how policy can collide with and impede clinical care.
