Should Medicare only allow physicians to make prior authorization decisions?
H.R. 2433 requires Medicare prior authorization decisions, such as denying or approving medical treatment, to be made by physicians. Prior authorization requires obtaining approval from your health insurance company to receive a treatment or prescription, and currently, these decisions may be made by insurance staff. The bill also requires authorization criteria to be based on physician input, medical necessity, and mandates that data be transparent and made public on medical approvals and rejections. Sponsor: Rep. Mark E. Green (Republican, Tennessee, District 7)
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How do you feel?
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Opponents say
• "Implementation of a well-designed, evidence-based prior authorization program optimizes patient outcomes by ensuring that patients receive the most appropriate medications while reducing waste, error and unnecessary prescription drug use and cost. Prior authorization (PA) is an essential tool that is used to ensure that drug benefits are administered as designed and that plan members receive the medication therapy that is safe, effective for their condition, and provides the greatest value." Source: The Academy of Managed Care Pharmacy
• "This ambiguity creates significant risk. 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 [prior authorization] altogether, possibly leading to broader utilization controls elsewhere. Clarity is essential. The focus should be on physician review for denials, not on impeding efficient approvals that meet established rules." Source: Josh Mandel MD, Chief Architect for Health at Microsoft Research
• "Prior authorization criteria are based on scientific evidence, standards of practice, peer-reviewed medical literature, established clinical practice guidelines, as well as safety and efficacy data. The goal of prior authorizations is not to create undue burden on patients or to intentionally prevent access. Prior authorization barriers can be mitigated by a better understanding of the rationale for, and benefits of, prior authorizations." Source: Caroline Forrester, National Library of Medicine
Proponents say
• "A physician should be the one determining a patient’s course of treatment. Prior authorization is a roadblock to care - equivalent to a bureaucrat in the waiting room. Medicare and Medicare Advantage plan administrators should not be able to exercise a unilateral veto over a doctor’s prescribed treatment. It is this kind of red tape that creates frustration for healthcare providers and patients alike. We know that preauthorization leads to delays in care and worse health outcomes for patients - it’s time to put patients first. Preauthorization doesn’t do that." Source: Rep. Mark Green (Republican, Tennessee, District 7)
• "On behalf of the physician and medical student members of the American Medical Association (AMA), I am pleased to express our support for H.R. 2433, the ‘Reducing Medically Unnecessary Delays in Care Act of 2025.’ [...] PA determinations made by individuals lacking appropriate clinical expertise not only undermine the treating physician’s clinical judgment but also introduce inefficiencies that fall disproportionately on private medical practices, especially smaller or independent ones that lack the administrative infrastructure to absorb the high costs of compliance and fighting inappropriate denials. These burdens translate into real-world harm including delayed diagnoses, treatment interruptions, worsening conditions, and declining patient trust." Source: James L. Madara MD, American Medical Association CEO
• "The American College of Physicians strongly opposes prior authorization requirements that are overly burdensome and pull physician time away from where it should be, on caring for our patients. These bureaucratic delays in care are especially galling when decisions about needed care are not being reviewed by physicians who are trained and knowledgeable in that care. Reforms that seek to make the prior authorization process more transparent, like those proposed in the Reducing Medically Unnecessary Delays in Care Act of 2025, are critical to ensuring that our nation’s seniors are able to access the care that they need when they need it most." Source: Isaac O. Opole, President of the American College of Physicians
- What They’re Saying: Rep. Green Seeks to Reform Prior Authorization (Press Release)
- Prior authorization bill would require [that] true peers make decisions (American Medical Association (AMA)
- Bipartisan bill targets prior authorization transparency, physician decision-making (Fierce Healthcare)
- Bipartisan bill seeks to reform prior authorization (The Hill)
- Reducing Administrative Burden in Medicine (American College of Physicians)
- Rep. Mark Green's Largest Donors (OpenSecrets)
