The term "prior authorization" has become reviled on Capitol Hill. Yet legislation to limit health insurance pre-certifications has been held up time and again, not unlike the treatments and medicines that providers and patients complain health plans delay or deny.
Some lawmakers from both political parties believe this Congress will be different. One Republican thinks sharing his own personal story about health insurance red tape will spur his colleagues toward the finish line.
Related: CMS explores limiting insurers' use of prior authorizations
Rep. Dr. Greg Murphy (R-N.C.) needed surgery last year to remove most of a tumor in his pituitary gland, he said. Recovery involves a very careful balancing process to replace the hormones his gland can no longer produce or properly regulate, said Murphy, a practicing urologist and surgeon.
"It's like fine-tuning a piano. The pituitary is the secular soul of the body. It keeps everything in balance," Murphy said. "We're just using medicine so I can stay alive."
As Murphy tells it, things were going well until he revealed to his physician that mounting a flight of stairs had become a struggle. It was an unhappy condition for someone who used to "run 10 miles and not think about it," he said.
Murphy's endocrinologist determined a certain hormone was off, and wrote a prescription for a medicine the congressman could inject himself once a week.
The insurance company denied it. Murphy and his doctor appealed and lost. He was advised he had to try a daily shot first.
"So my endocrinologist wrote a prescription for the one-a-day medicine. And guess what?" Murphy said. The insurer said no to that, too.
After more than two months, all while dealing with exhaustion, Murphy got his medications. He must keep the daily supplies refrigerated, which require tricky logistics because he frequently travels between North Carolina, Washington and other job-related destinations.
"None of the data had changed in any of those appeals, and I didn't call up any specific lobbyists or any representative to try to pull any strings," Murphy said. "I only dealt with it as John Q. Citizen, and this is what I had to go through."
Prior authorization spreads as Congress ponders
Murphy, like many colleagues on both sides of the aisle, believes that health insurance companies have strayed from deploying this utilization management tool to prevent overtreatment and control spending and instead use prior authorizations as a way to simply cover less medical care and collect larger profits.
"The intent of all this pre-authorization is for either the physician to give up or the patient to give up. It has nothing to do with being medically necessary or anything like that," Murphy said.
Kaye Pestaina, director of the Program on Patient and Consumer Protection at the health policy research institution KFF, said it's difficult to track the prevalence of prior authorization denials because of a lack of public data. But about 17% of respondents in KFF surveys describe prior authorization and claims denials as problems, she said.
Providers have been sounding the alarm, and legislation to curtail prior authorizations has the enthusiastic support of organizations such as the American Medical Association and the American Hospital Association.
"Certainly over the last few years, [we've heard] from physicians and other providers themselves, who say there's more prior auth requirements than we've ever seen," Pestaina said.
In AMA surveys, doctors report care is delayed 93% of the time when pre-certification is required, and 29% of physicians say delays have led to serious adverse events.
“Prior authorization remains a serious barrier to timely, high-quality care for our patients," AMA President Dr. Bruce Scott said in a statement, referring to ongoing efforts including the introduction of the Reducing Medically Unnecessary Delays in Care Act of 2025 by Rep. Mark Green (R-Tenn.) and 14 cosponsors in March. The bill would require prior authorizations be overseen by physicians armed with medical standards for denials.
"We’re encouraged by the continued engagement from congressional leaders who have made meaningful progress in advancing solutions to this issue, even amid ongoing legislative challenges," Scott said.
The health insurance industry counters that prior authorization and other forms of utilization management are critical to constraining national health expenditures and to ensuring that patients only receive necessary, appropriate and safe care. Insurers also insist that many denials and delays in prior authorization approvals are the result of providers failing to follow proper procedures or omitting key information from their requests.
Insurers act as CMS, states step in
Nevertheless, insurers have come under increasing pressure and face lawsuits and new regulations from the federal government and the states. In response, major carriers such as CVS Health subsidiary Aetna, UnitedHealth Group subsidiary UnitedHealthcare and Cigna have tried to assuage providers and patients by changing their practices.
On Thursday, for example, CVS Health announced Aetna will bundle prior authorization requests for some cancer diagnostics. Cigna is positioning relaxed prior authorization requirements as part of a broader strategy to improve relations with providers and customers. UnitedHealthcare said in March that it will cut back prior authorization demands by 10%.
Providers have reacted skeptically and Washington is not appeased, however.
The Centers for Medicare and Medicaid Services instituted a rule in January that requires faster approvals and more transparency under Medicare, Medicaid, the Children's Health Insurance Program and the health insurance exchanges.
CMS Administrator Dr. Mehmet Oz may be looking to go further, according to a report from Bloomberg News. "This issue of pre-authorization is a pox on the system," Oz said during his confirmation hearing in March.
"We look forward to working closely with him and our allies in Congress to build on this momentum,” Scott said in his statement.
Bipartisan support on Capitol Hill
Regulations, however, are not necessarily permanent, and Congress can't take credit for them.
Democrats and Republicans in the House and Senate said they are still committed to passing legislation. That most likely would be based on the Improving Seniors' Timely Access to Care Act of 2024, they said.
The bill, a previous version of which unanimously passed the House in 2022 but failed to advance through the Senate despite bipartisan support, would have required Medicare Advantage insurers to resolve non-urgent prior authorization requests within seven days and urgent requests within 72 hours.
"I'm hopeful that we can get it passed and signed into law," said Senate Finance Committee ranking member Ron Wyden (D-Ore.).
Rep. Buddy Carter (R-Ga.), who chairs the House Energy and Commerce Committee's Health Subcommittee, did not offer specifics, but said he hoped to get a prior authorization bill passed.
Yet the Improving Seniors' Timely Access to Care Act never made it into the healthcare package proposed at the end of the year, even after lawmakers downsized it to essentially mirror the regulation CMS finalized in January.
When popularity is not enough to ensure a measure passes, it's generally because the leaders who set floor vote schedules have priorities they consider more pressing, said Leigh Feldman, a director at the consulting firm McDermott+.
"I still see it as telling that a bill that largely codified in statute what the administration had already done through regulation didn't make it over the finish line," Feldman said. "It tells me that there's a reticence here to go the rest of the way forward and actually enact some law."
Sources familiar with the issue, who spoke on background to discuss ongoing talks, said congressional leaders are looking at moving legislation. There has been some talk of attaching it to the tax-and-spending cuts bill the GOP is assembling, they said. More likely, they said, prior authorizations will have to wait until that contentious process concludes, which House Speaker Mike Johnson (R-La.) wants to happen this month.
