Prior Authorization

Background

Prior authorization is a process whereby physicians must obtain approval from a patient’s health insurer before providing care to ensure that the service is covered by the patient’s health insurance plan. This requirement creates a significant burden for physicians and their patient care team which can lengthen the process of diagnosis and treatment– potentially putting the health of the patient at risk.

In the practice of otolaryngology, ENT offices currently complete an average of over 40 prior authorizations each week, with many offices employing staff dedicated solely to the completion of this weekly administrative burden. To compound this issue, many basic ENT procedures not only require prior authorization, but must also keep up with varying standards from one health insurer to another. The ensuing result is a patchwork system that is increasingly complex and creates an administrative burden for medical practices, exacerbating delays in patient care and contributes to rising levels of physician burnout and stress. Congress can protect patients by reforming prior authorization.

The Reducing Medically Unnecessary Delays in Care Act of 2025 (H.R.2433)

The Reducing Medically Unnecessary Delays in Care Act of 2025 would create sensible rules to relieve the administrative burden physicians face with prior authorization under the Medicare, Medicare Advantage, or prescription drug plan programs.

This bipartisan legislation would:

• Require PA to be based on medical necessity based on written clinical criteria
• Seek input from actively practicing physicians both in creating clinical criteria and in issuing determinations
• Apply high-standard written clinical criteria for the purpose of PA review consistently
• Preserve transparency in the preauthorization process by making preauthorization requirements readily visible on its website, giving proper notice when new requirements are implemented, and providing clear reasoning for denials

The Improving Senior’s Timely Access to Care Act of 2025 (H.R. 3514/ S. 1816)

The Improving Senior’s Timely Access to Care Act of 2025 would set standards for prior authorization systems to meet overall several years, regarding electronic system accessibility, data protection and transparency, as well as timeline standards.

Specifically, the legislation would:

• Require all plans to implement a secure electronic system for processing prior authorizations in MA plans
• Require plans to report and disclose their use of technology (including AI) in decisions, as well as approval/denial rates, average response times, and number of grievances, among other items
• Conduct annual reviews to keep PA requirements timely
• Authorize the HHS to establish specific timeline standards
• Collect data over three years to analyze efficiency of the program

Resources

• Reducing Medically Unnecessary Delays in Care Act of 2025 (R. 2433)
• Improving Senior’s Timely Access to Care Act of 2025 (H.R. 3514/ S.1816)
• Practice Resources on Prior Authorization from the American Medical Association