This bill establishes new requirements for Medicare contractors and private Medicare plans to base prior authorization decisions strictly on medical necessity, involve practicing physicians in setting criteria, and increase transparency regarding their utilization review processes.
Mark Green
Representative
TN-7
The Reducing Medically Unnecessary Delays in Care Act of 2025 aims to establish stricter federal standards for prior authorization decisions made by Medicare contractors and private Medicare plans. This bill mandates that coverage denials must be based on clear, evidence-based clinical criteria developed with input from practicing physicians. Furthermore, it requires plans to post their authorization rules online, provide advance notice of changes, and publicly report approval and denial statistics. Finally, all final denials of care must be reviewed and issued by a qualified, board-certified physician.
New Act Forces Medicare Plans to Post Prior Authorization Rules and Justify Denials with Specialty Doctors
When you need a medical procedure or a specific drug, nothing is more frustrating than hitting the wall of “prior authorization”—that administrative hurdle where your insurance plan decides if they’ll actually pay for it. The Reducing Medically Unnecessary Delays in Care Act of 2025 is aiming to dismantle that wall, or at least make it transparent and medically sound.
This bill targets Medicare Administrative Contractors (MACs) and private Medicare Advantage (MA) plans, requiring that all their coverage decisions—especially denials—must be strictly based on medical necessity using clear, evidence-based clinical criteria. It’s a direct shot at the practice of denying care based on internal cost-saving rules or vague standards. The key takeaway: if they deny payment, they need to show their work, and that work needs to be backed by actual medical standards, not just administrative convenience.
The Rules of the Road: No More Secret Handshakes
One of the biggest wins for providers and patients is the transparency mandate laid out in Section 3. Currently, figuring out why your MA plan requires pre-approval for a specific MRI or physical therapy session can feel like cracking a safe. This bill changes that by requiring plans to post all their current prior authorization requirements and the underlying clinical criteria clearly on their websites. This information must be written in language that the public can actually understand. If you’re a provider, this means less time spent on hold trying to decipher the latest coverage guidelines, and more certainty about what you can prescribe.
Even better, the plans have to share their data. They must post statistics showing how many prior authorization requests they approved versus how many they denied, broken down by specialty and service. This shines a huge light on how aggressive a plan is about denying care. If Plan A denies 40% of knee replacement requests while Plan B denies 5%, that’s critical information for seniors choosing a plan during open enrollment.
Doctor Input and Specialty Review
For anyone who’s been told a procedure isn't covered because it “doesn’t meet criteria,” Section 3 offers a crucial safeguard. First, before a plan can create or significantly change its clinical criteria, it must get feedback from board-certified doctors who are actively practicing in the area the rules cover. These doctors must not be employees of the plan itself. This is designed to ensure the rules reflect current, real-world medical practice, not just theoretical cost models.
Second, and perhaps most importantly, the bill mandates that any final denial of coverage (an “adverse determination”) must be made by a physician who is board-certified or eligible in the same specialty as the patient's condition. This means if your cardiologist recommends a specific heart procedure, the person denying it can’t be a general practitioner or a nurse administrator; it must be a licensed specialist in cardiology or a related field. This provision directly addresses the common complaint that denials are often issued by medical professionals without the specific expertise needed to overrule a specialist’s judgment.
What This Means for Your Wallet and Your Time
If this bill becomes law, the immediate impact for a patient needing specialized care, like a complicated diagnostic scan or a new biologic drug, should be a faster, more medically justified approval process. For example, if you need a specific type of cancer treatment, the plan can no longer deny it merely because they lack an established standard for that niche treatment.
For the Medicare Advantage plans and MACs, this means significantly higher administrative costs and less leeway to use utilization management as a primary cost-saving tool. They will have to invest in systems to publicly report their data and hire specialty physicians to review denials. While the intent is to reduce unnecessary delays, the success hinges on how strictly the Centers for Medicare & Medicaid Services (CMS) enforces the requirement that clinical criteria are truly “evidence-based” and reflect “community standards of care.” But overall, this bill is a major step toward making sure medical decisions are made by doctors, not by spreadsheets.