The "Reducing Medically Unnecessary Delays in Care Act of 2025" aims to streamline healthcare access for Medicare patients by setting clear, physician-backed standards for preauthorization and ensuring transparency in coverage decisions.
Mark Green
Representative
TN-7
The "Reducing Medically Unnecessary Delays in Care Act of 2025" aims to streamline healthcare access for Medicare patients by setting clear standards for medical necessity determinations and preauthorization processes used by Medicare contractors, Medicare Advantage plans, and prescription drug plans. It mandates the use of evidence-based clinical criteria, requires physician input in developing these criteria, and ensures transparency through public posting of preauthorization requirements and statistics. The bill also requires that licensed and board-certified physicians make all preauthorization and denial decisions. Ultimately, this bill seeks to reduce unnecessary delays in care and ensure that medical decisions are based on sound medical judgment and nationally recognized standards.
Medicare Preapproval Shakeup: New Bill Sets Stricter Rules for Authorizing Your Care
This proposed legislation, the "Reducing Medically Unnecessary Delays in Care Act of 2025," tackles the often frustrating process of getting healthcare approved before you receive it under Medicare, Medicare Advantage, or Part D prescription plans. It sets new ground rules for these plans (and their contractors) when they use preauthorization, requiring decisions about covering services to be fundamentally based on "medical necessity" as defined by clear, written clinical criteria (SEC. 3). The core idea is to streamline approvals and cut down on delays that aren't medically justified.
Decoding the Doctor's Note: Stricter Standards for 'Medically Necessary'
The bill demands that any preauthorization rules or denials must stick to written clinical criteria grounded in medical necessity (SEC. 3). Plans can't just make up rules; they need to base them on nationally recognized standards that reflect typical medical practice, ensure quality care, are backed by evidence, and get reviewed annually. Importantly, these criteria must be developed with input from actively practicing, board-certified physicians before being implemented or changed (SEC. 3). So, if your doctor orders a specific treatment, the plan's decision to approve it should align with established medical guidelines and allow for flexibility based on your individual health needs, not just a rigid internal policy. The bill also states coverage can't be denied solely because a service lacks specific evidence-based standards if no independent standards exist for it (SEC. 3).
Lifting the Veil: More Transparency, Fewer Surprises?
Getting blindsided by preauthorization requirements could become less common under this bill. Plans would be required to post their current preauthorization rules, restrictions, and the detailed clinical criteria they use on their websites in easy-to-understand language (SEC. 3). They'll also need to publish statistics showing how often they approve or deny requests, broken down by things like specialty and reason for denial (SEC. 3). Furthermore, healthcare providers must get a 60-day written heads-up before any new or changed preauthorization rules kick in (SEC. 3). This transparency aims to give doctors and patients a clearer roadmap for approvals and reduce guesswork.
Who Makes the Call? Putting Doctors Back in the Loop
A key change involves who makes the final decision. The bill mandates that all preauthorization approvals and denials must be made by a licensed physician who is board-certified (or eligible) in the same specialty as the doctor requesting the service (SEC. 3). This aims to ensure that complex medical decisions are reviewed by peers with relevant expertise. While the goal is better clinical judgment, finding a matching specialist reviewer could potentially introduce new steps. The overall intent is to base decisions on medical understanding, reducing denials based purely on administrative hurdles, though plans and providers will need to adapt to these new operational requirements.