The Hidden Delay Between Your Diagnosis and Your Surgery

When I tell a patient they need a hip or knee replacement, their next question is usually some version of "when can we do it?" The honest answer is that it depends on your insurance.

Before I can schedule most surgeries, I have to get permission from your insurance company. This process is called prior authorization, and for most patients it is completely invisible. You do not see the phone calls, the paperwork, the peer-to-peer reviews with insurance company physicians, or the occasional denial. Sometimes we can do surgery the following week, if there is an opening and your insurance approves it quickly. Other times the process takes months, because the insurance company requires more physical therapy first or makes us do a peer-to-peer review, a phone call where I have to advocate for your surgery with one of their physicians.

What the research shows

A study presented at the AAOS 2025 Annual Meeting looked at nearly 4,000 commercially insured patients who underwent total hip replacement and found that prior authorization did not save money. Patients whose insurance required it had slightly lower preoperative function scores, experienced more denials, and waited about two days longer to get to surgery¹. The authors concluded that the process adds administrative burden without reducing costs.

A separate multicenter study across six states followed over 1,000 prior authorization requests for imaging and surgery from shoulder and sports medicine practices. When a fellowship-trained orthopedic specialist made the request, only 1.5% were denied. Nearly everything was approved, but each request still took an average of 19.5 minutes of staff time and delayed the patient by an average of 2.2 days².

The trend is getting worse

Medicare Advantage insurers fully or partially denied 7.7% of all prior authorization requests in 2024, up from 6.4% in 2023³. At the same time, the 2026 Medicare Physician Fee Schedule applied a 2.5% "efficiency" reduction to the work value of most surgical procedures, which was partly offset by an increase in the overall payment rate⁴, so practices are handling more paperwork on thinner margins. In the AMA's latest survey, more than 8 in 10 physicians said prior authorizations had increased over the past five years, and 95% said the process delays care⁵.

There is some movement in the right direction. In January 2024, CMS finalized its Interoperability and Prior Authorization rule. Starting in 2026, Medicare Advantage and Medicaid plans must decide standard requests within 7 calendar days (72 hours for urgent ones) and give a specific reason for every denial. For the first time, they also have to publicly report their approval and denial rates, and electronic prior authorization follows in 2027⁶.

What this means for you as a patient

If you are told you need surgery and your insurance requires prior authorization, the approval often comes within a few days. It can stretch to months if the insurer asks for more physical therapy first, requires a peer-to-peer review, or denies the request and we have to appeal, so ask your surgeon's office for a timeline.

A denial does not mean you do not need the surgery. Usually it means the insurance company wants more documentation, and your surgeon's office handles the appeal. Insurers also look at what you have already tried (physical therapy, injections, imaging) when they decide. If you have done that work and it has not helped, that history strengthens the case.

I do not think prior authorization is going away. I do think patients deserve to know that it exists and that it adds time. When a study of nearly 4,000 hip replacements shows no cost savings, we should be asking whether the process is serving anyone.

This article is general education, not medical advice for your situation. Every knee and hip is different — talk with your own doctor about your care.