Prior Authorization Services for Orthopedic Practices: Six Options to Consider

By Your Health Magazine Contributor

Your Health Magazine Contributor

. https://YourHealthMagazine.net

More Practice Management Articles

Prior Authorization Services for Orthopedic Practices: Six Options to Consider

An MRI order, joint replacement booking or injection request can trigger several administrative steps: gathering records, checking payer requirements, submitting documentation and following up.

For orthopedic practices with high authorization volume, outsourcing some or all of this work can reduce the administrative burden on staff. The important question is not simply which company offers prior authorization support, but which model fits the practice’s workflow, technology and staffing needs.

The six options below represent different approaches, including orthopedic-focused managed services, automation-supported workflows, financial-clearance services and platform-native authorization management.

Key Considerations

• Orthopedic-focused managed services may suit practices whose requests frequently stall because of documentation gaps.
• Automation-plus-specialist models may fit groups that want to keep part of the authorization process internal.
• Financial-clearance providers can combine authorization with eligibility and patient estimates.
• Platform-native services may be useful for practices already using the associated EHR or practice-management system.
• Submission time and payer decision time are different, and authorization does not guarantee that a claim will ultimately be paid.

What to Compare Before Choosing a Service

Prior authorization services differ considerably in what they actually handle.

Practices should compare:

• Documentation review
• Authorization submission
• Payer follow-up
• Denial and appeal support
• Peer-to-peer responsibilities
• EHR integration
• Status reporting
• Eligibility and financial-clearance services
• Pricing structure
• Order types and procedures covered

The following examples are based on publicly available information and are intended to illustrate the different service models available to orthopedic practices.

Davner

Davner offers a managed prior authorization service focused on orthopedic, spine and pain practices.

According to its public materials, the service handles authorization workflows for areas including advanced imaging, joint replacement, spine surgery, arthroscopy and injections. Its process includes reviewing records against payer requirements, identifying missing documentation, submitting requests through the appropriate payer channel and following up for a determination.

The company also describes support for certain denial appeals and multiple methods for submitting records, including EHR access, secure upload and fax.

Practices considering the service should clarify which responsibilities remain with staff, particularly verification of submitted information, missing clinical documentation and peer-to-peer reviews.

Pricing: Not publicly listed. Practices should request a quote based on their imaging, surgery and injection volume.

Infinx

Infinx combines automation with specialist support for prior authorization workflows.

Its public materials describe determining whether authorization is required, initiating requests electronically when payer workflows permit and routing cases to specialists when manual processing is necessary.

The service also describes payer follow-up, EHR updates and web-based status visibility.

This model may appeal to practices interested in automation while retaining specialist support for cases that cannot be completed electronically.

Practices should ask which payers and procedures can be handled automatically and which require manual intervention.

Pricing: Public information describes annual engagements beginning at $5,000 per month, although that figure is not necessarily an authorization-only price. Practices should request an itemized proposal.

AGS Health

AGS Health incorporates prior authorization into a broader financial-clearance workflow.

Public materials describe checking authorization requirements, initiating submissions and following cases through completion. Its broader services can also include eligibility verification, patient estimates and preregistration.

This approach may be useful for orthopedic groups that want to address several pre-service administrative functions through one vendor rather than outsourcing authorization alone.

Practices should determine which services are included in the proposal and which require additional technology or implementation work.

Pricing: Not publicly listed. Request pricing that separates prior authorization from other financial-clearance services.

Outsource Strategies International

Outsource Strategies International provides insurance-verification and prior authorization support.

Its orthopedic-related materials describe coverage verification, payer communication, authorization forms and documentation support, along with communication of verification information.

The company advertises several pricing structures, including full-time-equivalent, flat-fee and transaction-based arrangements.

Published examples for verification and eligibility should not be assumed to represent the cost of prior authorization work, so practices should request authorization-specific pricing.

Pricing: Authorization-specific pricing is not publicly listed.

NYX Health

NYX Health describes outsourced teams that work within a practice’s existing EHR and payer systems.

Its managed workflows can include intake, documentation review, submission, payer follow-up and tracking of final determinations. The company also describes reporting on authorization volume, turnaround times, denials and appeals.

This type of model may suit practices that need additional operating capacity without replacing their existing technology.

Practices should clarify whether they are purchasing software, a hybrid service or a fully managed workflow because staff responsibilities can differ between configurations.

Pricing: Not publicly listed. Request a quote specifically for the managed-service configuration needed by the practice.

athenaOne Authorization Management

athenaOne Authorization Management is a managed service within the athenaOne environment.

For eligible orders, specialists can check authorization requirements, submit documentation and follow up on requests. Status information is available within the platform’s Authorization Tracker.

Because it operates within athenaOne, this option is primarily relevant to practices already using the required athenaOne products.

Practices should also review exclusions carefully. Public information indicates that certain categories, including durable medical equipment, therapy pre-certifications, medications and authorization appeals, may fall outside the service.

Pricing: Offered as an add-on, with no public price listed.

How to Choose the Right Prior Authorization Model

Start by identifying where authorization requests most often stall.

If requests are repeatedly returned because clinical documentation is incomplete, a service that reviews records against payer requirements before submission may be useful.

If the primary problem is volume, compare specialist capacity, turnaround expectations and the vendor’s ability to manage surges around imaging and surgical schedules.

Documentation quality also begins before an authorization request is submitted. Information such as symptoms, physical findings and previous treatment may first be documented during a patient’s first orthopaedic consultation, making clear clinical documentation important throughout the authorization process.

Practices should also compare responsibilities rather than price alone.

Ask each prospective provider who is responsible for:

• Obtaining missing records
• Checking payer-specific requirements
• Updating changed service dates
• Following up with payers
• Managing denials
• Handling appeals
• Coordinating clinical escalation
• Arranging peer-to-peer reviews
• Updating the EHR
• Communicating authorization status to staff

Getting these responsibilities in writing can make it easier to compare services that otherwise appear similar.

Prior Authorization Does Not Guarantee Payment

Practices should also distinguish authorization from payment.

A payer’s authorization indicates that the requested service met the applicable authorization requirements at that point in the process. It does not necessarily guarantee that the eventual claim will be paid.

Claims can still be affected by eligibility, coding, medical necessity requirements, plan limitations and other factors.

Likewise, a vendor’s submission turnaround should not be confused with the payer’s decision time. A service may submit a completed request quickly while the payer takes additional time to review it.

The Bottom Line

Prior authorization services for orthopedic practices use several different operating models.

Some focus heavily on orthopedic documentation and managed authorization workflows. Others combine automation with human specialists, incorporate authorization into broader financial clearance or operate directly within an existing EHR platform.

Rather than choosing a provider based on a ranking, practices should identify where their current process is failing and compare vendors against the same workload and responsibility requirements.

Before signing an agreement, request itemized pricing, confirm which procedures and payers are covered and obtain a written explanation of what the vendor handles versus what remains the responsibility of practice staff.

Frequently Asked Questions

What orthopedic procedures typically require prior authorization?

Advanced imaging, joint replacement, spine surgery, arthroscopy and interventional pain procedures commonly require prior authorization, although requirements vary by payer, plan and procedure.

Does prior authorization guarantee that the claim will be paid?

No. Authorization confirms that the payer approved the requested service under its authorization process, but the eventual claim may still be denied for other reasons.

What’s the difference between submission time and payer decision time?

Submission time describes how quickly a completed request is sent to the payer. Decision time is how long the payer takes to review and determine the request.

Can platform-native authorization services handle every order type?

Not necessarily. Some services exclude particular categories such as equipment, medications, therapy authorizations or appeals. Practices should confirm covered order types before signing an agreement.