In The News

Emergency medicine physicians report an increase of patients in the ER for routine care due to insurance denials and prior authorization requirements.

Concerns are growing over a new pilot program by CMS that will introduce prior authorization requirements, including the use of AI, into Medicare FFS starting next year. Critics argue that the move could lead to delays or denials of care for seniors, who may already struggle with navigating complex healthcare systems, and may worsen existing inequities in access to treatment.

Humana announced it will eliminate about one-third of prior authorization requirements for outpatient services by January 2026 in an effort to simplify the process and improve patient care. The company also plans to publicly report prior authorization metrics and expedite decisions, aiming to approve 95% of electronic requests within one business day.

“Gold card” programs were created to ease prior authorization burdens for physicians with high approval rates, but early results suggest limited impact. While more states adopt similar laws, concerns remain about their effectiveness, equity, and ability to meaningfully reduce delays in patient care.

Medicare Advantage, while intended to offer cost-effective care, is increasingly under scrutiny for delays and denials that harm patients, particularly seniors with serious illnesses. A growing consensus points to the need for reform to ensure timely access to care, greater transparency, and protection for vulnerable populations.

Experts and medical societies are backing the Seniors’ Act, arguing that the bill would reduce patient wait times, increase transparency, and improve outcomes, especially in radiology and radiation oncology.

Lawmakers have reintroduced the Seniors’ Act with broad support from over 140 healthcare organizations. The bill would modernize and standardize the prior authorization process, reduce delays in care, and codify recent CNS rules.

With Congress stalled on prior authorization reform, over a dozen states have enacted or proposed laws to streamline the process and curb the use of AI in care denials. However, state actions have limits, as federal authority still governs self-insured employer plans and Medicare Advantage.

In a podcast with AEI, Dr. Mark McClellan, former FDA Commissioner and CMS Administrator, discusses the rapid growth of Medicare Advantage and the mounting pressure it places on the need for policy reform. He anticipates that the Seniors’ Act will be enacted in some form during the 119th Congress.

The Trump administration finalized a policy granting over $25 billion in increased payments to Medicare Advantage plans for 2026—an unexpectedly large boost benefiting major insurers—while signaling continued implementation of accuracy-focused reforms begun in 2023. Despite the funding increase, new CMS Administrator Mehmet Oz has pledged to address overpayments and prior authorization practices, reflecting growing bipartisan interest in reforming the program.

Representative Mark Green, M.D., reintroduces the Reducing Medically Unnecessary Delays in Care Act of 2025, a bipartisan bill that would require Medicare prior authorization decisions to be made by board-certified specialists using evidence-based criteria. Green and co-sponsors say the bill aims to reduce care delays, cut administrative burden, and return medical decision-making decisions to physicians.

During his confirmation hearing for CMS administrator, Dr. Memhet Oz pledges to rein in Medicare Advantage costs by targeting upcoding practices and reducing the number of procedures requiring prior authorization.

In a conversation with Medical Economics, AMGA’s Darryl Drevna emphasizes the need for CMS to eliminate burdensome prior authorization requirements in Medicare Advantage, highlighting their impact on care delays and vulnerable patients, while supporting efforts to improve health equity, access to treatment, and responsible use of AI.

Bruce A. Scott, M.D., President of the American Medical Association, urges Cigna to commit to the comprehensive reforms outlined in their 2017 consensus statement, including reducing the volume of prior authorization requirements.

In 2023, Medicare Advantage insurers made nearly 50 million prior authorization determinations, reflecting steady increases since 2021. About 3.2 million requests were denied, and despite appeals, these denials often cause delays in necessary care.

Bruce A. Scott, M.D., President of the American Medical Association, criticizes Congress for failing to address Medicare reimbursement cuts and prior authorization reform in the Continuing Resolution (CR).

Democratic Senate and House committee leaders urge CMS to strengthen oversight of MA plans, citing concerns about inappropriate delays and denials of care, as well as marketing abuses that compromise access to essential services for seniors and people with disabilities.

EviCore and similar companies prioritize profitability in their prior authorization processes, often resulting in rigid and outdated guidelines that lead to inappropriate denials and delays in patient care, despite claims of improving healthcare quality and safety.

Delays in patient care and harmful outcomes due to prior authorization have prompted calls for reform and legislative action.

Physicians emphasize that prior authorization delays significantly hinder timely and effective cancer treatment, often resulting in worse patient outcomes and increased emotional distress.

Cigna Group is scaling back its Medicare Advantage offerings in eight states, affecting around 5,300 members, as it prepares to sell its Medicare business for $3.3 billion and focus on expanding its Evernorth Health Services segment.

Experts question whether Medicare Advantage is more affordable than traditional Medicare, noting that high out-of-pocket costs and prior authorization hurdles in Medicare Advantage plans may contribute to affordability concerns.

While Congress struggles to address prior authorization issues, states are enacting more stringent regulations, with 23 states passing over 43 related bills recently, aiming to streamline processes and reduce administrative burdens on providers and patients.

The prior authorization process for specialty drugs delays patient access to necessary treatments, creating administrative difficulties for both physicians and specialty pharmacies.

In 2022, there were 46 million prior authorization requests, up from 37 million in 2019, with 10% of denials appealed and 83% of those appeals overturning the initial denial, according to research.

Centene will exit the Medicare Advantage market in six states in 2025, affecting about 3% of its membership, while maintaining presence in other markets, with CVS and UnitedHealth Group also active in these regions.

Nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services, according to research.

Seven insurers are exiting the Medicare Advantage or Part D markets in 2025.

Starting October 1, UnitedHealth Group’s new “gold card” program will exempt qualifying physician practices from prior authorization requirements for certain services.

Protesters were arrested outside UnitedHealthcare headquarters for alleged denial of care, while the company contends that it has resolved issues and prioritizes employee safety amid recovery from February’s cyberattack.

Evolving prior authorization regulations are being hailed for enhancing transparency and efficiency, but further legislative efforts are said to be needed to address gaps and reduce administrative burdens.

A Wall Street Journal analysis found that from 2018 to 2021, Medicare Advantage insurers claimed thousands of questionable or false diagnoses, leading to $50 billion in extra taxpayer payments without corresponding care.

Rep. Marsha Blackburn (R-TN) put out a press release regarding the reintroduction of the Improving Seniors’ Timely Access to Care Act, urging colleagues to support modernizing and streamlining the prior authorization process.

Rep. Earl “Buddy” Carter (R-GA) discussed Congress’s inability to pass the Improving Seniors’ Timely Access to Care Act and cited strong insurance industry lobbying as a major obstacle.

Congress reintroduced a bill to streamline Medicare prior authorization processes and prevent rollbacks of Biden administration reforms.

Medicare Advantage enrollees report treatment denials and delays in payment, leading to harmful outcomes in healthcare.

GAO found scant state oversight of plans’ prior authorization decisions. It found that none of the states sampled scrutinized a representative sample of claim denials or leaned on data to determine “the appropriateness of the full scope of plans’ prior authorization decisions.”

Seniors’ Act champion Senator Roger Marshall (R-KS) announced that the bill will soon be reintroduced after the Congressional Budget Office reduced its projected cost from $16 billion to zero.

Medicare Advantage (MA) insurers that impose prior authorization requirements on doctors in accountable care organizations (ACOs) should have to get them pre-approved by CMS, Sen. Sheldon Whitehouse (D-R.I.) said Wednesday.

Value-based care, increased competition and a standardized claims process all could help the problems in the U.S. health care system that are piling on to physician burnout, patient outcomes, and growing costs, said three experts who testified in Congress.

Medicare Advantage (MA) insurers that impose prior authorization requirements on doctors in accountable care organizations (ACOs) should have to get them pre-approved by CMS, Sen. Sheldon Whitehouse (D-R.I.) said Wednesday.

A recent voluntary, national survey by Premier shed new light on denied claims.

On April 4, the Centers for Medicare & Medicaid Services (CMS) released the Contract Year (CY) 2025 Medicare Advantage (MA) and Medicare Part D Policy and Technical Changes final rule (“Final Rule”), which included revisions to the regulations governing how MA organizations and Part D plan sponsors (referred to collectively throughout as “issuers”) compensate agents, brokers and third parties.

The Centers for Medicare and Medicaid is evaluating whether it needs to take further steps cracking down on health insurance companies’ prior authorization requirements.

The federal government is addressing delays caused by insurers requiring prior authorization before medical professionals can provide some care. Experts say speeding up the process can aid patients and cut healthcare costs.

As prior authorization has spread, delays in care have become normalized.

The new CMS rule aiming to streamline prior authorization signals a major step forward for primary care, but the process could still use some improvement, according to experts.

Advocates for quicker care joined the organizations responding to new Medicare rules that aim to speed up the prior authorization process and increase data sharing in medicine.

New federal rules requiring health insurers to streamline requests to cover treatments are being hailed as a good first step toward addressing a problem that’s increasingly aggravated patients and doctors.

Doctors are cheering the new federal rule announced Wednesday which will speed up health insurance company decisions on whether to authorize or deny medical care or treatments for millions of patients.

Advocates for quicker care joined the organizations responding to new Medicare rules that aim to speed up the prior authorization process and increase data sharing in medicine.

Hospitals and other healthcare providers hailed a newly published final rule designed to improve prior authorization and the electronic exchange of health information.

Physicians groups on January 17 hailed a new federal rule requiring health insurers to streamline and disclose more information about their prior authorization processes, saying it will improve patient care and reduce doctors’ administrative burden.

A federal rule released Wednesday aims to streamline the prior authorization process used by insurers to approve medical procedures and treatments. The move was welcomed by hospital and physician groups, as well as by members of Congress from both parties.

The Centers for Medicare and Medicaid Services finalized the CMS Interoperability and Prior Authorization Rule on Wednesday. CMS said the rule will improve the prior authorization process and save about $15 billion over 10 years.

The Biden administration moved Wednesday to force insurance companies to give specific reasons for denying coverage, and to speed up the pre-approval process in general.

U.S. President Joe Biden’s administration on Wednesday finalized a rule requiring health insurers to set time targets for the prior authorization process for patients seeking approval for medical services under government-backed insurance plans.

The Biden administration on Wednesday finalized requirements to streamline the process for doctors and patients seeking health insurance approval for medical care and treatments.

Payers have new deadlines to issue prior authorization decisions — 72 hours for urgent requests and seven days for non-urgent ones.

Under a final rule released today, impacted payers will be required to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests.

A final rule from the Centers for Medicare & Medicaid Services (CMS) setting time limits and other requirements related to prior authorizations drew generally positive reviews Wednesday from healthcare organizations, although some expressed concerns about specific provisions.

To combat growing criticism of prior authorization delays by payers, Centers for Medicare & Medicaid Services finalized a rule Wednesday that requires health plans to send prior authorization decisions within three days for urgent requests and seven days for standard requests starting in 2026.

Physicians groups on January 17 hailed a new federal rule requiring health insurers to streamline and disclose more information about their prior authorization processes, saying it will improve patient care and reduce doctors’ administrative burden.