Limits on care denials in Medicare stall again

Driving the news: Efforts to streamline the prior authorization process in Medicare Advantage have come close in recent sessions of Congress before stalling over cost concerns.

• This year, one such measure — which would take steps to require insurers to cut down the time to make decisions and adopt electronic systems to smooth the process — was left out of the health package that was folded into the latest government funding deal.
• "It's a missed opportunity, but it's not the last opportunity," said Charlene MacDonald, CEO of the Federation of American Hospitals. "That certainty that seniors are going to get the care that they deserved in a timely manner is still important."

Between the lines: Republicans and President Trump have increased their attacks on health insurers, including bringing in executives for a hearing last month that showcased bipartisan concerns over prior authorization.

• "Republicans today sound a lot like Democrats have sounded for a long time, saying there's way too much profit, they're taking too much money out of the system," said Rep. Ami Bera (D-Calif.), who's pushing for changes.
• But it remains to be seen if the rhetoric translates into any action.

There were nearly 53 million prior authorization requests in Medicare Advantage in 2024, per KFF, with about 8% fully or partially denied. Government auditors have also found high rates of denials in Medicaid-managed care plans.

• The Biden administration tried to address the issue through regulations, but Congress split in 2024 on whether to simply codify those rules or add changes backed by Democrats that addressed the use of AI to deny medically necessary care.
• The legislation considered this year was scored as having no new costs, in part because it would make permanent steps already taken in regulation. But there were lingering questions about whether Medicare administrators will need more money to implement changes.
• Insurers continue to argue the pre-treatment reviews are necessary to weed out unnecessary and low-value care and contain health costs.

The intrigue: An added complication is a Trump administration push to test introducing more prior authorization in traditional Medicare.

• That test, known as the WISeR model, aims to save money by cutting down on unnecessary procedures, in part by using AI.

• Rep. Greg Landsman (D-Ohio) has introduced legislation to block the move. The House Energy and Commerce Committee held a hearing last month, but it is not expected to take action and block a Trump administration initiative.
• A CMS spokesperson said the program "is limited to a few procedures that have been demonstrated to be overutilized or abused" and that "all non-affirmation is done by clinicians," not AI.

The other side: Even those backing prior authorization changes acknowledge the reviews play a part in lowering health care spending.

• The insurer group AHIP says the process ensures "every health care dollar is spent wisely," which "helps hold down out-of-pocket costs for patients and premiums for everyone."
• The insurance industry made voluntary pledges last year with the Trump administration to simplify the practice.
• Insurers are also not actively opposing the proposed Medicare Advantage changes — and some, like Humana, have endorsed the bill.

What we're watching: Whether prior authorization resurfaces in another must-pass bill or remains a political talking point.

The bottom line: Bera said the process can be used for double-checking high-cost or rare treatments. "What we've seen over the last two decades, though, is that a lot of the health plans have started to just routinely prior auth things that don't need to be prior auth'ed," he said.

• "It's become more of a hassle factor, delay factor, often delaying care."