What’s the news: Only specialty board-certified physicians in the same field as the treating physician would be allowed to review prior authorization treatment decisions in Medicare, Medicare Advantage and Part D prescription drug plans if recently reintroduced bipartisan legislation that the AMA supports ultimately becomes law.
In late March, Representatives Mark Green, MD, (R, Tenn.) and Kim Schrier, MD, (D-Wash.) reintroduced H.R. 2433, the Reducing Medically Unnecessary Delays in Care Act of 2025. The bill calls for additional transparency in prior authorization determinations, and would also require that Medicare, Medicare Advantage and Medicare Part D plans make decisions based on medical necessity and written clinical criteria.
“The overuse of prior authorization is a persistent obstacle that prevents patients from receiving quality care from their physicians,” AMA President Bruce A. Scott, MD, said in a news report. “Often, prior authorization requests are reviewed—and denied—by insurance company representatives who lack the medical expertise to appropriately judge what level of care is necessary for a patient.
“This much needed legislation would require the reviewers to be physicians with actual experience in the field of medicine they are passing judgment over. Our patients deserve no less,” Dr. Scott added.
In addition to the AMA, about two dozen other medical associations support the bill, including the American Osteopathic Association, American College of Emergency Physicians, American College of Physicians and American Academy of Family Physicians. The bill also has support from the GOP Doctors Caucus and 14 cosponsors.
The AMA is fighting to fix prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
Why it’s important: Prior authorization is an insurance delay tactic that harms patients and wastes physicians’ time and resources.
“Physicians consistently report that [prior authorization] processes, while intended to promote appropriate care and manage costs, too often result in care delays, administrative burden and interference with medical decision-making,” James L. Madara, MD, the AMA’s CEO and Executive Vice President, wrote in a letter to Reps. Drs. Green and Schrier (PDF) supporting the bill.
“When these determinations are made by individuals lacking the relevant clinical training or familiarity with the patient’s condition, the consequences for patient safety and timely access to care can be severe,” Dr. Madara added.
Among physicians the AMA surveyed (PDF) in late 2024, 94% said they believe that prior authorization requirements negatively affect patient clinical outcomes. In other survey findings, 23% of physicians said prior authorization requirements have directly led to patient hospitalizations, while 18% reported that it has led to a life-threatening event and 82% reported that the tactic often or sometimes results in their patients abandoning a recommended course of treatment.
Meanwhile, only 16% of physicians who participated in peer-to-peer reviews for prior authorization reported that the health plan’s “peer” often or always had the appropriate qualifications.
“This bill takes an important step toward reforming prior authorization processes that continue to impose unnecessary delays and administrative burdens on physicians and patients by requiring that determinations about medical necessity are made by board-certified physicians with clinical experience in the same specialty as the ordering physician,” Dr. Madara wrote.
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When individuals without the appropriate clinical expertise make prior authorization determinations, it undermines a treating physician’s clinical judgment and the inefficiencies 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,” Dr. Madara said in the letter.
That, in turn, further exacerbates financial instabilities that practices already face.
“For many practices already operating on thin margins, these risks can mean the difference between sustainability and closure. As a result, [prior authorization] is not merely an administrative issue, but it is a growing threat to the viability of private practice and to equitable access to care across communities,” Dr. Madara wrote in the letter, which also told legislators that the AMA looked forward to helping advance the bill.
Learn more: Visit AMA Advocacy in Action to find out what’s at stake in fixing prior authorization and other advocacy priorities the AMA is actively working on.
The Reducing Medically Unnecessary Delays in Care Act of 2025 aligns closely with the AMA’s “Prior Authorization and Utilization Management Reform Principles” (PDF). A broad, multi-stakeholder consensus process produced the 21 principles that focus on prior authorization needing to be clinically valid, transparent, timely and administratively efficient.
Also, the bill complements recent Centers for Medicare & Medicaid Services regulatory efforts to impose meaningful guardrails on prior authorization in Medicare Advantage plans.
