Orthopedic Prior Authorization: Automating PA for Surgical Procedures
Illustrative Revenue Cycle Automation Scenario. This scenario demonstrates how a healthcare organization could apply revenue-cycle automation. It is not presented as an actual customer result.
The Challenge
An orthopedic group performed joint replacements, spine surgeries, and sports medicine procedures — many requiring prior authorization. PA submissions were manual, involving faxed forms and portal entries. Turnaround time for auth approvals averaged 7–10 business days, delaying surgeries. Approximately 15% of PA requests were initially denied, requiring peer-to-peer reviews that further delayed care.
The Approach
Sarva's PA automation layer was configured with orthopedic-specific payer requirements for common procedures including joint replacement, ACL reconstruction, and spinal fusion.
Clinical documentation was automatically retrieved from the EHR and packaged with PA submissions to support medical necessity.
Status tracking was automated, with escalations triggered when PAs were pending beyond 48 hours.
Peer-to-peer review preparation packets were auto-generated for denied PAs, including relevant clinical evidence and talking points for the physician.
Illustrative Outcomes
Outcomes are illustrative and do not represent actual customer results.
Key Lessons
- Automated PA submission with complete clinical documentation significantly reduces initial denials.
- Peer-to-peer review preparation packets improve overturn rates and reduce physician prep time.
- Proactive status tracking prevents delayed procedures by surfacing pending PAs before they become critical.
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Frequently Asked Questions
No. This is an illustrative scenario demonstrating how an orthopedic practice could apply revenue-cycle automation. The metrics shown are illustrative, not actual customer results.
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