A bipartisan group of physician legislators has introduced legislation in the House of Representatives to reform payer use of prior authorization.
Congress is considering a bill that would place new restrictions on prior authorization (PA) for payers participating in federal health programs.
Rep. Mark Green, MD (R-Tennessee) introduced the Reducing Medically Unnecessary Delays in Care Act of 2025 legislation in the House of Representatives last month.
Co-sponsored by, among others, GOP Doctor Caucus Co-Chair Greg Murphy, MD (R-North Carolina) and Democratic Doctors Caucus Co-Chair Kim Shrier, MD (D-Washington), the bill would require physician review of PA denials and increased transparency from payers regarding PA criteria and denial rates.
What would the bill do?
A key component to the bill, which would apply to all Medicare Administrative Contractor (MAC), Medicare Advantage, and Part D prescription drug plans, would require PAs and adverse determinations be made by licensed, board-certified physicians.
The bill would also require impacted plans to establish and to publish online clinical criteria for PA requirements. These criteria would need to align with current evidence-based standards, and payers would need to evaluate and update PA requirements at least once per year.
For services without accepted evidence-based standards, the lack of standards would be insufficient to deny coverage.
The intent behind the bill is to give providers more control over care decisions and reduce the administrative burden on provider organizations, according to lawmakers. According to American Medical Association (AMA) data, physicians and their staff are spending an average of 16 hours per week on PA-associated tasks.
There is also growing concern over the use of AI by payers in PAs.
“Doctors need to be able to make fast, life-saving decisions without a jungle of red tape to cut through,” Green said in the press release.
“No one should lose out on medical care because an AI algorithm is challenging what a doctor has already deemed a necessity,” Schier added in the press release. “As a physician myself, I've seen firsthand how prior authorization has created life threatening barriers to essential and standard care.”
What are RCM executives saying?
Revenue cycle leaders and their clinician colleagues have seen claim denial rates explode over the past several years, and they’ll likely welcome any legislation that aims to streamline PA approvals.
“Often, prior authorization requests are reviewed—and denied—by insurance company representatives who lack the medical expertise to appropriately judge what level of care is necessary for a patient,” AMA President Bruce Scott, MD, said in a statement.
While revenue cycle leaders are eager for laws that simplify their workflows, they should be wary of unintended consequences.
Ambiguous language in the bill could hamper the pursuit for increased efficiency, according to Josh Mandel, MD, chief architect for Microsoft Health.
“This ambiguity creates significant risk,” he wrote in a recent post on LinkedIn. “Mandating physician review for every routine approval would drastically increase costs, introduce potentially massive delays for necessary care (ironically contradicting the proposal's title), and could disincentivize the use of PA altogether, possibly leading to broader utilization controls elsewhere.”
Beyond the bill
Green introduced similar legislation in 2022 and 2023, and it remains to be seen whether the third time is a charm. However, this effort is part of a larger trend among lawmakers to target payers’ claim denial practices.
At least 10 states passed laws in 2024 to create new rules around prior authorization requirements. Some states have new laws going into effect in 2025, while others have kicked off their 2025 legislative sessions with new proposals.
Of course, legislative processes are not known for their fast pace. For revenue cycle leaders who want to get off the sidelines and onto the playing field, consider these tips from Amanda Bessicks, executive director of government and vendor relations at Baptist Health in Northeast Florida, for working with your organization’s government relations team.
Luke Gale is the revenue cycle editor for HealthLeaders.
KEY TAKEAWAYS
A bill recently introduced in Congress would require payers participating in federal health programs to implement physician review of prior authorization decisions.
The bill would also require increased transparency on denial rates and around criteria for prior authorization.
Lawmakers are increasingly targeting claim denial practices as denial rates continue to rise.