Study Finds Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved

Hackensack University Medical Center study shines light on issue of prior authorization denials that delay care

Prior authorization denials of orthopedic imaging requests and followed by requested peer-to-peer reviews and ultimate approval to proceed can delay treatment and increase administrative burden.

Hackensack University Medical Center researchers Rocco Bassora, M.D., Chris Cherian, M.D., Eitan Kohan, M.D., Francis Alberta, M.D., and John Koerner, M.D., contributed to a study recently published in Orthopedics that sought to quantify the approval rate of peer-to-peer reviews and evaluate the process’s efficiency in the context of advanced imaging application in an orthopedic practice.

The study enrolled patients at a single outpatient orthopedic clinic who initially received an insurance denial for computed tomography or magnetic resonance imaging, requiring peer-to-peer review over a ten-month period.

If imaging was approved after peer-to-peer review, the date of the imaging study and brief results were recorded.

In this orthopedic specialty practice, the study found almost all peer-to-peer reviews were approved, with the suspected diagnosis confirmed by imaging in most cases. For these patients, the originally recommended care was delayed.

Of 62 total denials, one was approved prior to peer-to-peer review. Fifty-eight (95.1%) reviews were ultimately approved, of which 51 (87.9%) patients completed the imaging.

While peer reviewers were always physicians, of those whose specialty was known, its notable none were orthopedic surgeons.

The median number of days from visit to peer-to-peer review was 9.0, and the median number of days from visit to imaging center appointment was 13.5 for approved studies. Of the 51 approved studies completed by patients, the results of 38 (74.5%) confirmed the suspected diagnosis.

The study results affirm the need for reform to improve review process efficiency, for more expedient patient treatment and to reduce clinics’ additional administrative and financial burden related to the review process.

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