Bipartisan Push to Overhaul Prior Authorization: What It Means for Providers, Payers, and Patients
Bipartisan Push to Overhaul Prior Authorization: What It Means for Providers, Payers, and Patients
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Prior authorization (PA), the process insurers use to approve medical treatments or medications, is under scrutiny. Nineteen states have passed laws limiting stringent PA requirements due to delays in patient care. At the federal level, bipartisan support is growing for reform, with Republican Rep. Mark Green (TN) and Democratic Rep. Kim Schrier (WA) reintroducing the Medically Unnecessary Delays in Care Act of 2025. The bill requires peer-to-peer appeals for Medicare and Medicare Advantage denials to be handled by board-certified specialists in the same field as the prescribing physician.
Prior authorization (PA), the process insurers use to approve medical treatments or medications, is under scrutiny. Nineteen states have passed laws limiting stringent PA requirements due to delays in patient care. At the federal level, bipartisan support is growing for reform, with Republican Rep. Mark Green (TN) and Democratic Rep. Kim Schrier (WA) reintroducing the Medically Unnecessary Delays in Care Act of 2025. The bill requires peer-to-peer appeals for Medicare and Medicare Advantage denials to be handled by board-certified specialists in the same field as the prescribing physician.
State and Federal Changes
Key Provisions
The legislation ensures specialists, not generalists, review PA appeals. For example, only an orthopedist would evaluate a knee replacement appeal, addressing concerns about inappropriate denials. Rep. Green stated, “We’ve got to let doctors focus on treating patients. This bill will reduce frustration in the prior authorization process for Medicare recipients.”
Implications for Payers
Requiring specialist-led appeals could raise costs for insurers, who often rely on generalist staff for PA reviews. Payers may need to hire or contract specialists, potentially slowing appeals if expertise is limited. This could force payers to rethink PA workflows.
Balancing Reform and Oversight
PA reform is widely supported but raises concerns about over-prescription by some providers if restrictions ease too much. Without checks, this could increase healthcare costs or lead to unnecessary treatments, challenging PA’s role in utilization control.
Key Provisions
The legislation ensures specialists, not generalists, review PA appeals. For example, only an orthopedist would evaluate a knee replacement appeal, addressing concerns about inappropriate denials. Rep. Green stated, “We’ve got to let doctors focus on treating patients. This bill will reduce frustration in the prior authorization process for Medicare recipients.”
Implications for Payers
Requiring specialist-led appeals could raise costs for insurers, who often rely on generalist staff for PA reviews. Payers may need to hire or contract specialists, potentially slowing appeals if expertise is limited. This could force payers to rethink PA workflows.
Balancing Reform and Oversight
PA reform is widely supported but raises concerns about over-prescription by some providers if restrictions ease too much. Without checks, this could increase healthcare costs or lead to unnecessary treatments, challenging PA’s role in utilization control.
The Future of Prior Authorization
PA is moving toward efficiency and patient focus, driven by these trends:
Automation
AI and electronic health record integration can streamline PA, speeding approvals for routine cases. CMS is pushing electronic PA to reduce delays, but systems must ensure clinical accuracy.
Regulatory Oversight
Future reforms may mandate faster approvals or limit PA’s scope, easing provider burdens but challenging payers’ cost controls.
Value-Based Care
PA may shift to align with outcomes-based metrics, reducing volume but requiring payer-provider collaboration to ensure appropriate care.
Second-Order Effects
Cost Increases
Specialist-led appeals could raise payer costs, potentially increasing premiums. Higher utilization may also drive up healthcare spending.
Provider Autonomy
Less PA oversight may enable over-prescription by some providers. Payers could use audits or analytics to monitor patterns.
Patient Access
Faster PA processes could improve outcomes and adherence but may strain resources like specialist availability.
Payer-Provider Dynamics
Reforms may strain relationships, with payers tightening other controls like formularies to offset reduced PA leverage.
PA is moving toward efficiency and patient focus, driven by these trends:
Automation
AI and electronic health record integration can streamline PA, speeding approvals for routine cases. CMS is pushing electronic PA to reduce delays, but systems must ensure clinical accuracy.
Regulatory Oversight
Future reforms may mandate faster approvals or limit PA’s scope, easing provider burdens but challenging payers’ cost controls.
Value-Based Care
PA may shift to align with outcomes-based metrics, reducing volume but requiring payer-provider collaboration to ensure appropriate care.
Second-Order Effects
Cost Increases
Specialist-led appeals could raise payer costs, potentially increasing premiums. Higher utilization may also drive up healthcare spending.
Provider Autonomy
Less PA oversight may enable over-prescription by some providers. Payers could use audits or analytics to monitor patterns.
Patient Access
Faster PA processes could improve outcomes and adherence but may strain resources like specialist availability.
Payer-Provider Dynamics
Reforms may strain relationships, with payers tightening other controls like formularies to offset reduced PA leverage.
PA, Health Providers and Patients
The Medically Unnecessary Delays in Care Act and state reforms aim to streamline prior authorization, prioritizing patient access. While these changes could reduce delays, they risk higher costs and overutilization. Automation and value-based care will shape PA’s future, but collaboration among payers, providers, and regulators is key to balancing access and accountability.
The Medically Unnecessary Delays in Care Act and state reforms aim to streamline prior authorization, prioritizing patient access. While these changes could reduce delays, they risk higher costs and overutilization. Automation and value-based care will shape PA’s future, but collaboration among payers, providers, and regulators is key to balancing access and accountability.
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