Doctor Knows Best Act Eliminates Prior Authorization and Other Insurance Reviews Starting 2026

The 'Doctor Knows Best Act of 2025' aims to significantly reshape how healthcare services are approved and delivered. The core change? Starting January 1, 2026, both private insurers and federal healthcare programs will be banned from requiring prior authorization, using utilization management, or conducting medical necessity reviews for any covered item or service. Let's break down what that means in practice.

Cutting Through the Red Tape

The main idea here is to streamline healthcare access. Right now, if you need a specific treatment or medication, your doctor often has to get pre-approval from your insurance company – that's 'prior authorization'. This bill gets rid of that process entirely. Utilization management, which are strategies insurers use to control costs, and medical necessity reviews, where insurers check whether a service is really needed, are also going out the window. This applies to all private insurance plans starting with plan years on or after January 1, 2026, and to federal health programs from January 1, 2026, as stated in SEC. 2.

Real-World Rollout

Imagine you're a small business owner dealing with a chronic back issue. Currently, your doctor might recommend an MRI, but your insurance could require pre-approval, potentially delaying the scan. Under this Act, that delay disappears. Your doctor says you need the MRI, you get the MRI. Or, consider a construction worker needing a specific medication. Today, that might involve paperwork and waiting for insurer sign-off. Come 2026, if this bill passes as is, that hurdle is removed. The same goes for a freelance graphic designer needing a specialized procedure—no more jumping through hoops for insurance approval.

The Flip Side

While all of this sounds great for getting quick care, there are some serious questions. Without these checks and balances, what stops potential over-treatment or unnecessary procedures? For example, a doctor could, in theory, prescribe more expensive medications or tests when cheaper, equally effective options exist, because there is no oversight. This could drive up overall healthcare costs. Think of it like this: if you give someone a blank check, they might spend more than if they had a budget. This bill essentially gives doctors a blank check when it comes to ordering treatments and services.

The Big Picture

This act essentially shifts the balance of power from insurers back to doctors. It's designed to reduce paperwork and delays, which can be a huge relief for anyone dealing with health issues. But, it also removes key cost-control measures, raising concerns about potential impacts on insurance premiums and overall healthcare spending. It is important to remember that the purpose of prior authorization, utilization managment, and medical necessity reviews is to eliminate excessive and unnessecary treatments, which would now be allowed. Whether that trade-off – faster care versus potentially higher costs – is worth it remains to be seen.