Pre-authorization processes have no effect on patients undergoing knee MRI in a pediatric setting when evaluated by specialists

Pierce, Drew; Kan, J. Herman; May, Megan M.; Bisset, George S.

doi:10.1007/s00256-016-2509-1

Cited by 7 publications

(5 citation statements)

References 4 publications

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“…In the years following implementation of PA, just 1.5% of all claims for tonsillectomy were denied approval. Our findings are similar to those of other studies that demonstrate very low denial of PA claims (<4%) for elective surgery, prescription medications, and imaging studies 13,15–17 . Furthermore, no statistically significant reduction in the incidence of tonsillectomy was discovered after implementation of PA for government plans alone, commercial plans alone, or all plan types combined.…”

Section: Discussionsupporting

confidence: 89%

“…Our findings are similar to those of other studies that demonstrate very low denial of PA claims (\4%) for elective surgery, prescription medications, and imaging studies. 13,[15][16][17] Furthermore, no statistically significant reduction in the incidence of tonsillectomy was discovered after implementation of PA for government plans alone, commercial plans alone, or all plan types combined. The overall very low percentage of claims denied and subsequent lack of a reduction in the incidence of tonsillectomy raise the question of whether PA is effective in eliminating overuse of health care resources and thereby decreasing associated over expenditure.…”

Section: Discussionmentioning

confidence: 95%

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What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

Torrecillas

Neuberger

Ramirez

et al. 2020

Otolaryngol.--head neck surg.

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Objective Third-party payers advocate for prior authorization (PA) to reduce overutilization of health care resources. The impact of PA in elective surgery is understudied, especially in cases where evidence-based clinical practice guidelines define operative candidacy. The objective of this study is to investigate the impact of PA on the incidence of pediatric tonsillectomy. Study Design Cross-sectional study. Setting Health claims database from a third-party payer. Methods Any pediatric patient who had evaluation for tonsillectomy from 2016 to 2019 was eligible for inclusion. A time series analysis was used to evaluate the change in incidence of tonsillectomy before and after PA. Lag time from consultation to surgery before and after PA was compared with segmented regression. Results A total of 10,047 tonsillectomy claims met inclusion and exclusion criteria. Female patients made up 51% of claims, and the mean age was 7.9 years. Just 1.5% of claims were denied after PA implementation. There was no change in the incidence of tonsillectomy for all plan types ( P = .1). Increased lag time from consultation to surgery was noted immediately after PA implementation by 2.38 days (95% CI, 0.23-4.54; P = .030); otherwise, there was no significant change over time ( P = .98). Conclusion A modest number of tonsillectomy claims were denied approval after implementation of PA. The value of PA for pediatric tonsillectomy is questionable, as it did not result in decreased incidence of tonsillectomy in this cohort.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 95%

What Is the Impact of Prior Authorization on the Incidence of Pediatric Tonsillectomy?

Torrecillas

Neuberger

Ramirez

et al. 2020

Otolaryngol.--head neck surg.

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“…There is a growing sense that these costs far exceed the benefits of preventing access to unnecessary care. 11 Of particular concern is that these burdens are sometimes designed to increase insurer profits rather than improve health care.…”

Section: What Are Health Care Administrative Burdens?mentioning

confidence: 99%

“…Kyle and Frakt (2021) found that a third of people reporting a billing problem or prior authorization requirement delayed or missed care. There is a growing sense that these costs far exceed the benefits of preventing access to unnecessary care 11 …”

Section: What Are Health Care Administrative Burdens?mentioning

confidence: 99%

Health care administrative burdens: Centering patient experiences

Herd

Moynihan

2021

Health Services Research

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Policy makers, physicians, and health care providers often bemoan excessive administration in US health care. It costs a lot of money. Its frustrating for providers to navigate. One study found that physicians spent twice as much time on paperwork as they did with patients. 1 Dealing with these administrative hassles is a leading cause of physician burnout. 2 While the growing administrative burdens that health care providers must negotiate is well documented, we know much less about patients' experiences. As a result, Michael

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“…The usual justification for this practice (which is both annoying and costly) is that by going through the steps of preauthorization it will provide assurances that the examination is appropriate and necessary. Pierce et al [3] reviewed 80 pediatric patients who were required to undergo pre-authorization prior to a knee MRI, and compared the findings on the examination to 44 patients who did not undergo pre-authorization. The authors found that there was no difference in the frequency with which surgically significant findings were present among the groups that had undergone preauthorization.…”

Section: The Practice Of Radiologymentioning

confidence: 99%