Prior authorization is no longer just a checkpoint in orthopedic care, It’s becoming a defining force in how, when and even whether patients receive treatment.
As payers expand algorithm-driven reviews and tighten requirements, surgeons say the impact is reshaping clinical decision-making, delaying care and straining practice operations.
The result is a growing disconnect between policy intent and real-world patient needs.
1. Standardized and algorithm-driven reviews are slowing orthopedic approvals: Orthopedic and spine leaders say prior authorization is increasingly driven by rigid criteria, AI screening and non-specialist reviewers, where approvals often hinge on specific documentation rather than clinical nuance.
As a result, even well-documented, medically necessary procedures can face delays of weeks or months, and in some cases denials, prolonging pain, worsening outcomes and disrupting timely access to care.
2. Prior authorization workflows are adding significant administrative strain across orthopedic care: Surgeons say the burden of navigating prior authorization extends far beyond simple approvals, often involving repeated documentation, denials, third-party reviews and time-sensitive, peer-to-peer calls, all before treatment can move forward.
“Prior authorization has seemingly prioritized standardized rules and checklists over personalized care and patient-centered decision-making,” Alex Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedics, told Becker’s.
3. Surgical scheduling is increasingly disrupted by authorization delays: Delays tied to prior authorization remain one of the most persistent and overlooked challenges in orthopedic practices, often forcing teams to anticipate hold-ups and adjust surgical timelines.
To manage this, some groups are investing in dedicated authorization teams, while others triage cases by acuity or limit certain procedures for specific payers.
“Being patient advocates, anticipating this delay and providing the necessary documentation helps expedite this process,” Madhish Patel, DO, orthopedic Surgeon at Fort Myers, Fla.-based Gardner Orthopedics told Becker’s.
4. CMS models are expanding prior authorization into traditional Medicare procedures: CMS’ Wasteful and Inappropriate Service Reduction model introduces prior authorization requirements for select procedures, including knee arthroscopy for osteoarthritis, as part of a broader push to reduce low-value care and control costs.
While the goal is to limit unnecessary procedures, leaders warn the added requirements could increase administrative burden, delay access and shift decision-making toward standardized, technology-driven criteria that may not fully capture individual patient needs or clinical nuance.
5. Prior authorization is adding costs and delays without clear savings: While payers use prior authorization to control spending, recent research suggests it may do the opposite in orthopedic care. One study of total hip arthroplasty found prior authorization requirements increased time to surgery, added administrative costs per submission and required weeks for processing and payment, despite more than 90% of requests ultimately being approved.
The findings also showed patients subject to prior authorization had longer wait times and lower preoperative functional scores, raising questions about whether these policies improve value or simply add friction to care delivery.
At the Becker's 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, taking place June 11-13 in Chicago, spine surgeons, orthopedic leaders and ASC executives will come together to explore minimally invasive techniques, ASC growth strategies and innovations shaping the future of outpatient spine care. Apply for complimentary registration now.
