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Orthopedic Prior Authorization Denials Are Rising — Here’s What the Data Shows

Posted on by Reviora Healthcare LLC in Uncategorized

Reviora Healthcare LLC | Guaranteed Revenue Partner

Every denied prior authorization is a surgery pushed back, a patient who may not come back, and revenue your practice already staffed for but can’t collect. If that cycle feels like it’s happening more often this year, it’s not your imagination — it’s showing up in the national data too.

Is Prior Authorization Denial Actually Getting Worse?

Yes, and physicians are saying so directly. Three in four physicians (74%) report that denials have increased over the past five years, per the AMA’s 2025 Prior Authorization Physician Survey. On the request side, 86% of medical group leaders told MGMA in a 2025 MGMA Stat poll that prior authorization requirements themselves have increased in the past year — not just denials, but the volume of procedures now requiring approval before you can even schedule them.

For orthopedic practices specifically, this matters more than most specialties. Surgical and imaging-heavy care — the backbone of orthopedic volume — sits squarely in the outpatient category where payers have been tightening review criteria.

What’s Actually Driving the Increase?

Two forces are colliding: more procedures requiring authorization, and less clinical rigor behind the denials themselves. Nearly one in three physicians (32%) report that PA requests are often or always denied, according to the AMA’s 2025 survey. At the same time, only 24% of physicians say medical necessity denials are consistently reviewed by an appropriately qualified clinician, despite payer commitments to do exactly that.

That gap — high denial volume paired with thin clinical review — is why appeals often succeed when practices have the bandwidth to pursue them. The problem is most practices don’t.

What Does This Actually Cost an Orthopedic Practice?

Time, first — and time is money in a fee-for-service model. Physicians complete an average of 40 prior authorizations per week, per the AMA’s 2025 survey, with the 2024 survey putting the associated staff time at roughly 13 hours weekly. That’s a full administrative shift, every week, before a single claim is even submitted.

Then there’s the claims side. Kodiak Solutions’ Revenue Cycle Analytics, which tracks financial data from more than 1,850 hospitals and 250,000 physicians nationwide, found initial prior authorization and precertification denials on outpatient claims rose 16% from 2021 to 2023 — and inpatient claims rose 26% in the same window. Outpatient is where the bulk of orthopedic scheduling lives: imaging, injections, scoped procedures, and elective surgery.

MGMA’s 2026 Regulatory Burden Report adds another layer: 92% of surveyed medical group practices said they’ve had to hire or reassign staff specifically to keep up with prior authorization volume. That’s headcount spent chasing approvals instead of growing the practice.

What Can Practice Owners Actually Do About It?

Start by separating what you can control from what you can’t. You can’t control payer policy. You can control how tightly your intake, coding, and submission process is run before a request ever reaches a payer — because most denials on the front end are procedural, not clinical.

This is where credentialed human oversight matters more than software alone. Automated PA tools can flag missing fields; they can’t catch a payer’s shifting medical-necessity criteria or build the appeal that gets a legitimate case overturned. That takes a specialist who knows the payer, the CPT code, and the clinical documentation standard cold.

That’s the model behind Reviora Healthcare LLC’s approach: Expert-Led Technology, where credentialed specialists — not algorithms — drive every claims and authorization decision, with technology supporting their judgment rather than replacing it. Our orthopedic RCM work is governed by a Managed Outcomes Agreement (MOA) — a written, contractual performance agreement built around specific benchmarks — backed by a Benchmark Recovery Protocol that triggers a root-cause audit and corrective action plan if performance slips two months in a row. It’s accountability built into the contract, not a promise made in a sales call.

If your denial rate has crept up and you’re not sure whether it’s payer behavior or something fixable in your own workflow, that’s worth a real conversation. Book a free 30-minute consultation and we’ll walk through what your numbers are actually telling you.

Related reading: Orthopedic RCM Services | Claims Submission & Denial Management | The Reviora Guarantee

FAQ

Why are prior authorization denials going up for orthopedic practices? Payers have expanded which procedures require authorization while clinical review of denials has grown thinner — only 24% of physicians report denials are consistently reviewed by a qualified clinician, per AMA’s 2025 survey.

How much staff time does prior authorization actually take? Physicians complete an average of 40 PA requests weekly, with roughly 13 hours of associated staff time reported in AMA’s Prior Authorization Physician Survey data.

Are prior authorization denial rates the same across all insurers? No. KFF’s 2025 analysis of standard PA requests found denial rates ranging from 12% to 18% depending on the market segment (Medicare Advantage, Medicaid managed care, and ACA Marketplace).

What can a practice do to reduce denials without adding staff? Tightening front-end intake, coding accuracy, and documentation before submission catches most procedural denials before they happen — which is where a specialist-led RCM partner focuses first.

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