Surgical teams know the drill: before you book the OR, you need the prior auth. But what happens when the process itself introduces risk?

In working with orthopedic and surgical groups, Bo Bowman, VP of Strategic Accounts, Infinx, has seen how prior authorization—when mishandled—can lead to unnecessary delays, denials, and compliance exposure. And the most costly issues aren’t always obvious.

Here are the five biggest hazards your team might be missing.

1. “Approved” Doesn’t Mean Payable

An authorization is not a payment guarantee. Payers can—and do—approve procedures with fine print disclaimers. That means the surgery may proceed, but the claim still gets denied due to diagnosis code mismatch, missing documentation, or a technicality in medical necessity requirements.

What to do: Use payer-specific checklists. Don’t just verify that an auth was obtained—verify that it aligns with coding and documentation rules for that payer and that CPT.

2. Stat Cases Fall Through the Cracks

Emergent surgical cases can’t wait days for prior auth. But many systems treat all procedures the same—leaving stat cases stuck in a backlog or missing the urgency flag entirely.

The result: delayed care, or unapproved surgeries that lead to denials.

What to do: Segment surgical orders by urgency. Build workflows that recognize stat procedures and route them to dedicated queues or payer portals with built-in exceptions.

3. Incomplete Orders = Invisible Denials

Too often, prior auth teams are asked to submit cases without complete documentation—no chart notes, no diagnosis codes, no clinical rationale. These cases get denied, but the reason isn’t always obvious until weeks later.

What to do: Create hard stops in your order entry process. If required fields aren’t populated, the request shouldn’t advance to prior auth submission.

4. Retro Authorizations Put You at Risk

When surgeries are performed before an auth is obtained, teams scramble to get retro approval. It happens. But in Medicare Advantage or commercial plans, it’s a compliance risk—and a denial waiting to happen.

What to do: Monitor your retro auth rate. If more than a few cases a month are slipping through, that’s not an exception—it’s a broken workflow.

5. If You’re Only Tracking Turnaround Time, You’re Missing the Story

Turnaround time is useful—but it doesn’t show how many requests were approved the first time, how many were delayed, or why denials happen in the first place.

What to do: Track metrics that actually indicate performance:

  • First-pass approval rate
  • Denials by category (e.g., missing info, invalid CPT, timing issues)
  • Ratio of stat to standard cases
  • Time from scheduling to auth confirmation

Final Thought

Surgical prior authorization isn’t just a paperwork step—it’s a process full of risks. Denials, delays, and missed handoffs happen behind the scenes unless you’re actively measuring and improving them.

Want to dive deeper? Watch the full Office Hours episode here.