Orthopedic Prior Authorization Automation: Where It Helps and Where Human Judgment Still Matters

Prior authorization in orthopedics is not one administrative task. It commonly appears around imaging, medications, durable medical equipment, and elective procedures, with different requirements depending on the payer, plan, service, and clinical circumstances.

The American Academy of Orthopaedic Surgeons has described prior authorization as a significant administrative burden for orthopedic practices and a potential barrier to timely patient care. That burden is especially important in a specialty where authorization work can touch several different points in the care journey before treatment is delivered.

That breadth is what makes orthopedic prior authorization a useful candidate for automation, but also an easy workflow to automate badly.

The goal should not be to remove people from every step. It should be to separate repetitive payer work from the decisions that genuinely require clinical or revenue cycle judgment.

Why orthopedic prior authorization becomes complicated so quickly

Consider a patient being evaluated for surgery.

Before the procedure takes place, the practice may need to confirm coverage, determine whether authorization is required, obtain the payer's documentation requirements, submit clinical information, monitor the request, respond to additional-information requests, document the approval, and make sure the authorized service matches what is eventually scheduled and billed.

A different patient may need an MRI first. Another may require a brace or other DME. Another may be waiting on a medication authorization.

Each case can follow a different path even though staff think of all of them as “prior auth.”

The administrative burden is not unique to orthopedics. Across specialties, the AMA's 2025 Prior Authorization Physician Survey found that physicians complete an average of 40 prior authorizations per week, while physicians and their staff spend an average of 13 hours each week completing prior authorization work. Forty percent of surveyed physicians reported employing staff dedicated exclusively to prior authorization tasks.

Those figures should not be treated as orthopedic benchmarks, but they illustrate why high-volume specialty practices often devote substantial staff capacity to the process.

CAQH data also shows how much the communication channel matters. In its 2024 Index, providers and staff reported spending an average of 24 minutes on a prior authorization conducted through phone, fax, or email, compared with 16 minutes through a health plan portal. CAQH also found that specialists generally spent more time and therefore more money on prior authorization than generalists because of the complexity of their services.

For an orthopedic practice, the opportunity is therefore not simply to “automate prior auth.” It is to identify which portions of the workflow are repetitive enough to automate reliably.

Automate the requirement check before the case gets complicated

One of the highest-value moments occurs before a request has even been prepared.

Does this patient's plan require authorization for this specific service?

That answer may depend on the payer, plan, procedure, place of service, diagnosis, and other details. A payer-level rule is not enough if different products from the same insurer have different requirements.

When staff discover an authorization requirement late, the consequences can spread into scheduling and clinical operations. The team may need to delay a procedure, contact the patient, gather documentation under time pressure, or reschedule care.

Automation can help by moving the requirement check earlier in the workflow and returning a structured answer that includes the source of the information.

The important distinction is that automation should retrieve the payer requirement, not make an independent clinical determination about whether a procedure is medically necessary.

Those are different jobs.

Automate routine status follow-up

Once an authorization has been submitted, a large share of the remaining administrative work may consist of asking the payer what happened.

Was the request received? Is it pending? Has it been approved? Was additional information requested? Was it denied? When should the practice check again?

These questions are well suited to automation because the task is primarily information retrieval.

Staff should not have to repeatedly log into portals or call payer representatives simply to learn that a request is still under review.

A useful automated workflow can perform the status check through the available payer channel, capture the response, and return information such as:

• current authorization status,
• payer reference or authorization number,
• missing documentation,
• effective and expiration dates,
• approved units or visits when applicable,
• and the appropriate next action.

The value comes from returning an operational result, not simply completing a phone call or portal session.

Treat missing documentation as an exception, not just a status

“Pending” is often not enough information.

An authorization may be waiting because the payer needs imaging results, therapy notes, a physician note, additional clinical history, or some other supporting material.

A basic automation system may record the case as pending and check again later. A better workflow distinguishes between a request that is genuinely under review and one that cannot progress until the provider does something.

That difference determines who should receive the case next.

Automation can identify that the payer is requesting additional information and route the exception to the appropriate team. Clinical staff can then decide what documentation should be supplied and whether the request is clinically appropriate.

This is an important boundary.

The machine can retrieve the payer's request and organize the work. It should not be expected to replace clinical judgment about the contents of a medical record.

Keep peer-to-peer review human

Orthopedic prior authorization sometimes moves beyond administrative follow-up into medical necessity review.

AAOS guidance on prior authorization discusses next steps after denial and includes specific guidance for peer-to-peer review, underscoring the point that some cases eventually require direct clinical involvement.

A peer-to-peer discussion is fundamentally different from a status call. The physician may need to explain the patient's condition, previous treatment, diagnostic findings, and why a particular service is medically appropriate.

That is not the part of the workflow to automate away.

Automation can still reduce the surrounding administrative work. It can identify that peer-to-peer review is required, preserve the payer's instructions and reference information, route the case to the correct clinician, and track what needs to happen afterward.

The goal is to get physicians to the point where their expertise is actually required without asking them to perform the administrative work that precedes it.

Denials need classification before they need automation

A denial does not automatically tell the practice what should happen next.

One request may have been denied because required documentation was missing. Another may involve a coverage rule. Another may need a corrected submission. Another may require an appeal or clinical review.

Treating every denial as one workflow can create as much confusion as treating every prior authorization as one workflow.

Automation is useful for retrieving the denial reason, capturing the payer's instructions, recording relevant reference numbers, and routing the case. Human review remains important when the next step depends on clinical judgment, interpretation of payer policy, or an appeal strategy.

This division of labor matters because the purpose of automation is not to maximize the percentage of cases that never touch a person.

It is to minimize the amount of human time spent on work that does not require human expertise.

Do not stop the workflow at approval

An approval can still create downstream problems if it is not connected to scheduling and billing.

The authorization number needs to be recorded correctly. Effective dates need to match the planned service. Approved units or visits may need to be tracked. The authorized service needs to correspond to what is ultimately performed and billed.

This is where prior authorization becomes a revenue cycle problem rather than simply a utilization-management task.

An automated workflow should therefore return the approval in a form that downstream teams can use. A result buried in a transcript or separate dashboard may still require staff to re-enter the information manually.

Structured fields make it easier for scheduling, authorization, and billing teams to work from the same result.

Measure touches per authorization, not just approval rate

Approval rate tells only part of the story.

Two authorizations can both end in approval while consuming radically different amounts of staff effort.

One may be approved after a clean submission and one status check. Another may require three portal checks, two calls, a documentation request, and a manual escalation.

If both appear as “approved” in reporting, the operational burden is invisible.

Orthopedic practices trying to understand whether automation is helping should also measure:

• staff touches per authorization,
• payer interactions per case,
• time from submission to usable decision,
• percentage of cases requiring additional information,
• percentage routed for clinical review,
• authorization-related scheduling delays,
• and authorization-related denials downstream.

Those measures reveal whether the workflow is actually becoming easier to operate.

The right model is automation around clinical judgment

Orthopedic practices do not need an AI system deciding whether surgery, imaging, medication, or DME is appropriate for a patient.

They need less administrative friction around the people who make those decisions.

That means automating requirement checks where possible, retrieving payer instructions, monitoring status, capturing denial reasons, documenting approvals, and routing exceptions with enough context for the next person to act.

Clinical judgment stays with clinicians. Complex appeals stay with the people equipped to handle them. Ambiguous payer responses can be escalated instead of forced through an automated path.

The result is not a fully autonomous prior authorization department.

It is a workflow where staff spend less time asking payers for routine information and more time resolving the cases that actually need their attention.

For orthopedics, where one practice may be coordinating imaging, equipment, medications, procedures, and follow-up across many health plans, that distinction matters more than simply increasing the number of tasks labeled “automated.”

Frequently Asked Questions

What kinds of orthopedic care may involve prior authorization?

Orthopedic prior authorization commonly appears around imaging, medications, durable medical equipment, and elective procedures. The exact requirement depends on the patient's payer, plan, service, and clinical circumstances.

AAOS has separately documented the broader administrative burden that prior authorization creates for orthopedic practices.

Can orthopedic prior authorization be fully automated?

Parts of it can be automated effectively, particularly requirement checks, routine status follow-up, payer information retrieval, documentation of responses, and routing. Cases involving medical necessity decisions, peer-to-peer reviews, complex appeals, or ambiguous clinical information generally require human judgment.

Why are status checks a good candidate for automation?

Status follow-up is repetitive and usually involves retrieving a defined set of information from the payer. Automating those interactions can reduce the time staff spend navigating portals, waiting on hold, and documenting routine responses.

Should automation handle prior authorization denials?

Automation can retrieve and structure denial information and route the case according to the response. Whether a denial should be corrected, resubmitted, appealed, or reviewed clinically depends on the circumstances and may require human expertise.

What should an automated authorization result include?

The useful fields depend on the workflow, but commonly include authorization requirement, current status, authorization or reference number, missing information, effective and expiration dates, approved units or visits where relevant, the source of the payer response, and the next action.

The takeaway

Orthopedic prior authorization is a strong candidate for automation precisely because so much of the process surrounds clinical judgment rather than constituting clinical judgment itself.

The repetitive work is finding requirements, checking status, contacting payers, recording responses, following up, and moving information between systems. The high-value human work begins when the case requires interpretation, medical necessity review, peer-to-peer discussion, or an appeal.

The most effective automation strategy keeps that boundary clear.

Automate the retrieval. Structure the answer. Preserve the evidence. Route the exception.

Then let people spend their time on the parts of orthopedic care and revenue cycle management that actually require them.

Sources

• American Academy of Orthopaedic Surgeons. Prior Authorization Resources.‍
• American Academy of Orthopaedic Surgeons. Resident Perspectives on Prior Authorization: The “Hidden Curriculum” Underlying the Administrative Burden. May 28, 2026.
• American Medical Association. 2025 AMA Prior Authorization Physician Survey. Released May 2026.
• CAQH. 2024 CAQH Index.

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