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

Abstract

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.

Is There Utility to Requiring Spine MRI Pre-authorizations? Pre-authorizations

“…Ultimately, 96.57% of all ordered scans had been completed within 3 months of the original request. Such high approval rates are consistent with previous studies, such as: dermatologic procedures (99.6%),4 pediatric tonsillectomies (98.5%) 5…”

“…Such high approval rates are consistent with previous studies, such as: dermatologic procedures (99.6%), 4 pediatric tonsillectomies (98.5%). 5…”

Multi-Institutional Analysis of Insurance Denial Patterns Within Rhinology

“…Insurance companies claim that prior authorizations assist in decreasing healthcare consumption and costs, but results are conflicting with some even suggesting that appropriate clinical decisions are altered to avoid prior authorizations. [3][4][5] Among the many complexities of the US healthcare system, approval for procedures can be a complex and costly process for physicians and patients alike. Institutional-level data regarding lost revenue due to denials is scarce, but health systems have been estimated to lose 3% to 5% of revenue as a result of insurance denials.…”

“…Insurance companies claim that prior authorizations assist in decreasing healthcare consumption and costs, but results are conflicting with some even suggesting that appropriate clinical decisions are altered to avoid prior authorizations. 3-5…”

Burden with No Benefit: Prior Authorization in Congenital Cardiology

“…Delays in treatment initiation have been found in pediatric neurology for anti-epileptics [ 11 ] and in pediatric gastroenterology for inflammatory bowel disease [ 12 ]. Requiring prior authorization for tonsillectomy showed a denial rate of 1.5%, no change in the overall incidence of tonsillectomy surgery, and an associated delay of 2.38 days from consultation to surgery [ 13 ]. These prior authorization processes provide additional stress to an already challenging economic environment for Children’s Hospitals.…”