Prior Authorization Services for Orthopedics

Gain Admin Efficiency Through Orthopedic Prior Authorization Requests

One of the main administrative tasks that causes significant overhead and delays in the orthopedic area is the prior authorization process required for the majority of treatments.

Most admin staff will be more than familiar with the burden of dealing with dozens of different insurers and a wide range of completely different electronic forms required for each prior authorization request.

The result of this growing admin overhead is burnout among staff and physicians and a significant impact on treatments and patient satisfaction.

Here at DataMatrix, we have first-hand experience of the impacts on orthopedic clinics. We have created this guide to help you better understand how outsourced prior authorization can transform your operational efficiency.


How Does The Prior Authorization Process Impact Orthopedic Clinics?

Because of the highly specialized medical services that orthopedic surgeons provide, there is a larger than standard administrative overhead in these departments.

Even with a modern electronic prior authorization process, admin staff quickly become overwhelmed, especially when it comes to errors and omissions in the requests.

In a best-case situation, insurers will provide decisions within four days. But more often than not, admin staff receive requests for further supporting information.

This leads to more time spent on researching the missing information, multiple resubmissions, and often many hours spent waiting on hold before getting through to a decision-maker with a patient’s insurance company.

Orthopedic clinics and departments also need to organize regular training for admin staff to stay on top of changes in prior authorization processes.

We’ll get to a more in-depth analysis of these issues shortly.

What Types Of Orthopedic Services Require Prior Authorization?

In the orthopedic medical space, healthcare providers face increasing demands from insurance companies to determine the medical necessity of the majority of treatments.

Here are some of the main treatments that require prior authorization, and there are many more:

  • Radiology and diagnostic tests
  • Intra articular injections
  • Joint arthroscopy
  • Hip replacements
  • Knee replacements
  • Spinal surgeries
  • Long-term medication treatments
  • Pain management injections

The difficulty with the prior authorization process is that it requires knowledge and experience in different submission systems with every insurance provider.

With a lack of overall consistency and standard request forms it’s one of the bottlenecks in the administrative process that has the biggest impact on patients.

Let’s take a closer look.

orthopedic prior authorizations


Challenges For Orthopedic Departments And Clinics

Satisfying all the prior authorization requirements for each insurer results in significant challenges for admin staff and physicians. And the impact is most notable in these five areas.

The American Medical Association has conducted extensive research into what impact the prior authorization process has on administrative staff. For a typical medical department, the average time associated with requesting authorizations based on phone calls or online submission is 25 to 40 hours a week depending on the size of the organization.

In many situations, those hours are mainly spent on dealing with follow-up questions due to incomplete requests or errors in the submitted information. And because insurance companies have different systems and forms, it quickly happens that a prior authorization request doesn’t succeed on the first attempt.

That’s a large volume of work identified by the American Medical Association that is allocated to interacting with insurance company processes that limit how quickly patients can be treated.

The burden doesn’t end there, though.

Because insurers have different online systems and processes, and there are regular changes in the process and treatments covered, there is a significant need for regular training of admin staff.

That translates into more costs and additional time taken away from other admin tasks, further impacting the efficiency and effectiveness of an orthopedic department.

Even with minimum delays in the prior authorization process, it can take 4–5 days for insurers to deal with the request. That results in at least the same amount of time delay for a patient to be able to get the necessary treatment.

Whether it’s a simple arthroscopy procedure or complex spinal surgery, these delays have an impact on the patient’s experience.

The amount of time admin staff have to deal with requesting prior authorization and follow-ups also impacts patient care.

Just like in any other medical field, delays for orthopedic patients can impact the treatment outcome and increase the level of pain and discomfort they have to deal with.

In many instances, orthopedic patients are dealing with some level of pain. More often than not, any delays in treatments can have a negative impact on that pain.

This is where prior authorization has an indirect impact, making it a medical necessity for doctors to prescribe stronger pain medication for longer than would otherwise be required.

With delays due to incomplete prior authorization forms often leading into weeks, it can become a significant issue to manage. It also requires additional monitoring by doctors to ensure that patients don’t become dependent on medication.

At a time when patients are looking forward to getting through their treatment and on the road to recovery, dealing with pain and long delays also has significant impacts on quality of life and the ability to take care of everyday tasks.

Another indirect impact on orthopedic clinics is that delayed treatments also lead to delayed billing.

When patients are active in the system for longer than is medically necessary, it impacts the ability to issue medical bills to insurance providers.

Not only does it lead to delayed billing, but due to the limitations on the number of patients that physicians can see, there is an impact on overall revenue as well.

That’s why DataMatrix has developed a tailored service for orthopedic clinics to free up a lot of valuable time by eliminating administrative overhead.

Benefits Of Outsourcing Prior Authorization Requirements

Here at DataMatrix, we specialize in providing outsourced services for radiology prior authorizations. We can speak from experience about the major benefits to physicians, clinical staff, admin staff, and, most importantly, the patients.

A major issue that most hospitals and clinics have is that they get inconsistent results when requesting prior authorization.

With every insurer having different forms, systems, and information requirements, it becomes a maze with constantly increasing complexity.

Staff need to be experts in all the different systems, and they require regular retraining to deal with new treatments and authorization requirements.

Our team at DataMatrix has specialists in all types of authorization requests for orthopedic treatments with all insurance providers.

And through our dedication to constant training, we have been able to ensure that we maximize the success rate of authorization requests on the first submission, thereby limiting follow-up tasks to a minimum.

With a fully outsourced prior authorization process, your involvement will be kept to an absolute minimum.

From the perspective of administrative staff and physicians, it will involve providing the information about the treatment being requested, and our team at DataMatrix ensures that the forms are populated and submitted in the correct way.

If we identify issues or missing information, we’ll request that before submitting requests to avoid unnecessary follow-ups.

It’s a service that aims to keep your involvement to a minimum.

When you can free up staff and physicians from having to deal with many hours of frustrating follow-ups and spending time on hold with insurance companies, it immediately becomes a noticeable efficiency gain.

All those hours trying to ensure forms are filled correctly or following up for missing information can now be dedicated to many of the other important tasks in a busy orthopedic clinic or department.

One of the most important business metrics for healthcare providers is overall patient satisfaction.

Unfortunately, even when treatments are delayed due to factors outside of your control, it still reflects badly on an orthopedic clinic or department and its staff.

With a streamlined prior authorization process offered by DataMatrix and a significant reduction in delays, it will have a positive impact on patient satisfaction.

In addition to shorter turnaround times for starting treatment, the freed-up time for physicians can result in shorter waiting lists, further improving the patient experience.

“Datamatrix has been a long-term partner who has handled our prior authorizations for the past seven years. Without this co-sourced initiative, we would not be able to process these requests in a timely manner.” ORTHONY


Call us today to find out more about how DataMatrix can help you with prior authorization requirements and ensure that you eliminate delays.

With a large dedicated team specializing in the needs of orthopedic clinics, we are in the ideal position to streamline all prior authorization needs.

We can also quickly adapt to increased demand at busy times of the year, further reducing strain on your administrative teams.

This will be one phone call that could transform efficiency and patient satisfaction with a highly scalable solution.