The prior authorization process has long been a pain point for orthopedic practices. It's time-consuming, often inconsistent, and loaded with administrative inefficiencies that can delay patient care and hurt your bottom line. Fortunately, there is now artificial intelligence (AI) in orthopedics to simplify this burden. These new, modern solutions can help orthopedic surgeons automate and improve this critical, but frustrating, part of clinical workflows.
Leveraging artificial intelligence in orthopedics for prior authorizations can help reduce delays, eliminate errors, and free up staff to focus on what matters most: patient care.
AI tools can integrate with your electronic health record (EHR) and payer portals to verify insurance coverage in real time. These systems identify whether prior auth is required for a particular procedure or imaging order before anyone on your team has to pick up the phone or log into a payer site.
This reduces wasted time and effort and helps ensure your practice isn’t blindsided by unexpected denials that could delay surgeries, frustrate patients, or cause reimbursement issues down the line.
A significant portion of prior authorization denials result from mismatched or incomplete coding. AI tools can read your clinical documentation using natural language processing (NLP) to automatically suggest the most appropriate CPT and ICD-10 codes based on payer requirements or verify that the coding that has already been completed is correct.
This is especially valuable in orthopedics, where surgical indications must be clearly justified and documented (e.g., conservative therapy before total joint replacement).
Using AI to support documentation and coding ensures that everything aligns precisely with payer expectations to reduce denials and appeals.
One of the most valuable AI tools for orthopedics (and nearly every specialty) is ambient listening tools, which can then be used to automatically draft prior authorizations or help with appeals.
These tools are able to listen in during the patient visit and generate structured clinical notes. The notes can be automatically analyzed to extract the key components of medical necessity, which are then populated into payer-specific pre-auth forms or electronic portals. This eliminates copy-pasting from notes and minimizes staff time spent formatting or duplicating information.
AI tools can maintain real-time databases of payer guidelines and alert your staff when documentation or clinical criteria have changed. For example, if a particular insurance carrier has updated its protocol to require six weeks of physical therapy before approving an MRI. In that case, the AI tool can notify you of this change during the documentation process, so you can adjust as needed. This gets your team ahead of the game to ensure that you’re meeting these changing requirements and prevents denials or issues with reimbursements.
Keeping up with payer-specific authorization rules is a full-time job—and one that’s prone to human error.
Some AI tools use machine learning to flag “high-risk” submissions based on patterns from thousands of prior cases. These predictive models help your team proactively correct or supplement prior authorization requests before you send them.
Reducing the number of denials and appeals in your practice allows you to speed up care, reduce frustration among staff and patients, and increase collections to improve cash flow.
Even with perfect documentation, some denials are inevitable. AI can help streamline this frustrating process.
AI tools can generate appeal letters, find missing documentation, and resubmit the request to the correct payer using templates and large language models (LLMs). This dramatically reduces the time between denial and resubmission, which helps your patients get the care they need faster. Some AI solutions can also suggest supporting studies or clinical guidelines to strengthen your case.
AI significantly reduces the administrative burden typically associated with prior authorizations for orthopedic practices. By consolidating the critical information, automating tracking and requirements, and making it easy to handle appeals, your practice can:
In high-volume practices, where prior auths are needed for everything from MRIs to joint replacements, the time and cost savings add up quickly. If you're not already exploring AI-powered prior authorization tools, now is the time to start.
Artificial Intelligence is beginning to reshape the landscape of orthopedic practices, particularly in areas like prior authorization, clinical documentation, and operational efficiency. While the potential is clear, navigating the AI landscape is anything but simple. Identifying the right solutions, ensuring they're a good fit for your practice, and integrating them into your workflows can be a significant undertaking.
At TRIARQ, we work closely with orthopedic surgeons to explore how AI might best support their practice goals: whether it’s improving day-to-day operations or laying the foundation for long-term strategy. Our 20 years of experience building systems for independent practices provides us with a strong understanding of what works in orthopedics and what doesn’t.
We’re here to help you make informed decisions about which tools to consider, how to prepare your operations, and how to align new technologies with your existing practice infrastructure.
The future of orthopedic care will undoubtedly involve AI, and our goal is to help you approach it strategically and at your own pace, so you can continue delivering exceptional care while staying ahead of the curve.