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

Author:

Torrecillas Vanessa F.1,Neuberger Kaden2,Ramirez Alexander3,Krakovitz Paul1,Meier Jeremy D.1

Affiliation:

1. Department of Otolaryngology, University of Utah, Salt Lake City, Utah, USA

2. School of Medicine, University of Utah, Salt Lake City, Utah, USA

3. Intermountain Hospital, Salt Lake City, Utah, USA

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.

Funder

national center for advancing translational sciences

Publisher

SAGE Publications

Subject

Otorhinolaryngology,Surgery

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