Bill Seeks to Reform Prior Authorization

For years, physicians and healthcare organizations have voiced concerns over the burdensome prior authorization process, which often delays necessary medical treatments and contributes to physician burnout. Now, a bipartisan bill introduced in the House of Representatives seeks to change that. The Reducing Medically Unnecessary Delays in Care Act would reform prior authorization requirements for Medicare and Medicare Advantage (MA) plans, ensuring that only board-certified specialists—rather than insurance company representatives—make decisions regarding medical necessity. 

If passed, this bill could significantly impact the way healthcare providers and insurers interact, ensuring that medical expertise, rather than bureaucratic red tape, dictates patient care. However, while many physicians and medical organizations have applauded the initiative, questions remain about its feasibility and potential unintended consequences. 

The Burden of Prior Authorization 

Prior authorization (PA) has long been a controversial aspect of healthcare administration. Initially designed to control costs and prevent unnecessary medical procedures, the process now serves as a significant barrier to timely care. According to a 2024 American Medical Association (AMA) survey, physicians and their staff spend an average of 16 hours per week—equivalent to two full business days—on PA-related paperwork. 

The administrative burden placed on medical professionals is not just frustrating—it can be life-threatening. Studies have repeatedly shown that delays caused by prior authorization lead to worsened patient outcomes, prolonged suffering, and even increased mortality rates. In fact, the AMA survey found that 94% of physicians reported that PA delays negatively impacted patient care, while 78% noted that the process led to treatment abandonment altogether. 

For patients dealing with serious illnesses, such as cancer or heart disease, these delays can mean the difference between life and death. Congressman Dr. Mark Green (R-TN), a survivor of colon and thyroid cancer, understands this struggle personally. “Prior authorization can be a roadblock that costs lives,” Green said. “Doctors need to be able to make fast, life-saving decisions without a jungle of red tape to cut through.” 

What the Bill Proposes 

The Reducing Medically Unnecessary Delays in Care Act introduces several key reforms aimed at improving transparency, efficiency, and fairness in prior authorization procedures: 

1. Board-Certified Physicians as Decision Makers: 

1. Under the proposed legislation, only board-certified specialists in the relevant medical field would be allowed to review and approve or deny PA requests. 

2. This would prevent insurance company representatives—who often lack the necessary medical training—from making critical healthcare decisions. 

2. Transparency Requirements: 

1. The bill mandates that Medicare, Medicare Advantage, and Medicare Part D plans publish their PA standards online. 

2. These standards must be regularly updated to reflect evidence-based medical guidelines rather than outdated or arbitrary insurer policies. 

3. Medical Necessity as the Standard: 

1. Any restrictions imposed by insurers must be based on clear, evidence-based medical necessity criteria. 

2. Physicians and patients would be able to challenge denials using standardized medical guidelines rather than vague or subjective criteria. 

These provisions aim to reduce unnecessary hurdles for patients and doctors while maintaining a level of oversight that ensures medical procedures are appropriate and justified. 

Why It Matters: The Impact on Physicians and Patients 

The bill has garnered widespread support from major medical organizations, including the American Medical Association, the American Osteopathic Association, the American College of Emergency Physicians, the American College of Physicians, and the American Academy of Family Physicians. 

Dr. Bruce A. Scott, AMA President, emphasized the significance of this reform: “The overuse of prior authorization is a persistent obstacle that prevents patients from receiving quality care. This welcome legislation would require reviewers to be physicians with actual experience in the field of medicine they are passing judgment over. Our patients deserve no less.” 

By shifting PA decision-making to specialists with real-world clinical experience, the bill aims to reduce unnecessary denials and improve patient access to timely care. Additionally, by making insurers publicly disclose their PA policies and justification criteria, the bill seeks to curb arbitrary denials and promote greater accountability. 

Challenges and Potential Roadblocks 

While the bill has received bipartisan support, there are concerns about its implementation and potential unintended consequences. 

• Insurer Pushback: 

• Insurance companies argue that prior authorization is a necessary tool to prevent overutilization and excessive healthcare costs. 

• If specialists reviewing PA requests are more inclined to approve treatments, this could increase overall healthcare spending—a cost that could ultimately be passed on to patients in the form of higher premiums or co-pays. 

• Administrative and Financial Burdens: 

• Requiring board-certified specialists to review every PA request could place an administrative strain on already overworked physicians. 

• The increased workload might require additional compensation for reviewing physicians, leading to questions about who will bear the financial burden—insurers, providers, or patients? 

• Impact on Medicare Advantage Plans: 

• Medicare Advantage plans already rely heavily on prior authorization to manage costs, approving nearly 50 million PA requests in 2023 alone. 

• If restrictions on PA approvals tighten, insurers may seek alternative cost-cutting measures, such as narrowing provider networks or increasing patient cost-sharing. 

The Bigger Picture: A Step Toward Systemic Reform 

The push for prior authorization reform is part of a broader movement to streamline healthcare administration, reduce inefficiencies, and prioritize patient-centered care. 

In recent years, Medicare and commercial insurers have faced mounting pressure to simplify or eliminate unnecessary prior authorization requirements. The Centers for Medicare & Medicaid Services (CMS) has already taken steps to reduce PA delays by requiring insurers to process requests more quickly and provide electronic PA options—but many argue that more aggressive legislative action is needed. 

If the Reducing Medically Unnecessary Delays in Care Act passes, it could serve as a model for further reforms, potentially influencing private insurance policies beyond Medicare and Medicare Advantage. 

For too long, prior authorization has been a bureaucratic barrier that places undue stress on physicians and delays critical medical care for patients. The Reducing Medically Unnecessary Delays in Care Act seeks to change that by ensuring that medical necessity decisions are made by board-certified specialists, rather than insurance representatives with little to no clinical experience. 

While the bill presents challenges, its potential to streamline care, improve patient outcomes, and reduce physician burnout makes it a crucial step in the ongoing fight to reform healthcare bureaucracy. As the legislation moves through Congress, its success will depend on continued bipartisan support and a commitment to placing patients before paperwork.