Prior authorization reform gains traction in Congress: What it means for your practice

Bipartisan legislation that would impose new requirements on how Medicare Advantage (MA) plans use prior authorization has assembled a rare level of congressional support, and health care organizations say its passage would deliver the most significant administrative relief for physician practices in years.

The Improving Seniors' Timely Access to Care Act of 2025 would require MA plans to adopt electronic prior authorization systems that integrate directly with physician electronic health records (EHRs), establish public transparency requirements around denial rates and approval timelines, and create a pathway for the Centers for Medicare & Medicaid Services (CMS) to mandate real-time decisions on routinely approved services.

According to the American Medical Association (AMA), more than 248 House members and 64 senators have signed on as co-sponsors, giving the bill supermajority-level backing in the upper chamber.

The administrative burden the legislation targets is substantial. AMA survey data from late 2024 found that practices complete an average of 39 prior authorization requests per physician per week, consuming roughly 13 hours of physician and staff time, the equivalent of nearly two business days. Nearly one in three physicians reported that prior authorization has led to a serious adverse event for a patient in their care, including hospitalization, disability or death. The survey also found that 93% of physicians said prior authorization contributes to delays in patient care, and 82% said it sometimes leads patients to abandon recommended treatment.

Practices with a high share of MA patients have the most at stake. MA now covers more than half of all Medicare beneficiaries, and MA plans use prior authorization at significantly higher rates than traditional Medicare. A 2022 Health and Human Services Office of Inspector General (HHS-OIG) report cited in the AMA's congressional letter found that 13% of prior authorization requests ultimately denied by MA plans would have been approved under traditional Medicare coverage rules.

The bill's prospects are stronger in the current Congress than in recent sessions, in part because CMS finalized an interoperability rule in 2024 that incorporated some of the legislation's requirements, significantly reducing the Congressional Budget Office's cost estimate for the remaining provisions. MGMA's analysis of the prior authorization landscape in 2025 notes that codifying the requirements in statute would make them more durable and harder to roll back than regulatory guidance alone, which has become a more pressing concern following the Supreme Court's 2024 Loper Bright decision limiting agency rule-making authority.

The legislation does not address commercial insurance prior authorization directly, and its passage would not eliminate the burden for practices with predominantly commercial or Medicaid patient panels. Several states have enacted their own prior authorization reforms for state-regulated health plans, with varying scope and enforceability. Practice administrators tracking both the federal and state dimensions of this issue can find current resources through the AMA's prior authorization reform page, which includes the full text of the congressional letter, specialty society co-signers, and tools for contacting representatives and senators directly.

In the meantime, practices should not wait on legislation to begin reducing their authorization burden. Identifying the top 10 service codes that generate the most prior authorization volume and working with payers to establish gold-card arrangements for high-volume, consistently approved services is a strategy that some practices have used to cut weekly authorization requests significantly. Several major insurers, including UnitedHealthcare and Cigna, have made public commitments to expand gold-carding programs, and practices can request these arrangements outside of formal contract renegotiation cycles.