Prior Authorization Reform Legislation Returns to the 119th Congress
The Improving Seniors’ Timely Access to Care Act (Seniors’ Act) was reintroduced this month by U.S. Senators Roger Marshall, M.D. (R-KS), and Mark Warner (D-VA), and U.S. Representatives Mike Kelly (R-PA), Suzan DelBene (D-WA), Ami Bera, M.D. (D-CA), and John Joyce, M.D. (R-PA). The bill numbers are S. 1816 and H.R. 3514.
BILL OVERVIEW/BIPARTISAN SUPPORT
The Seniors’ Act is bipartisan legislation that addresses the overuse and abuse of prior authorization (PA) by Medicare Advantage (MA) plans, thereby threatening patient access to care and increasing administrative burdens for providers.
Last Congress, the bill garnered support from a supermajority of Senate members (60), a majority in the House (232), and passed the House unanimously in 2022. Although CBO scoring hindered the bill’s passage in the 117th Congress, CMS finalized rules that implemented key provisions of the bill in January 2024, significantly lowering the score. The bills in the 118th House and Senate made further modest adjustments to the legislation, decreasing the score even more, and achieved a preliminary CBO score of zero in October 2024.
In short, the Seniors’ Act would:
- Establish an electronic prior authorization process for Medicare Advantage (MA) plans, including standardization of transactions and clinical attachments.
- Enhance transparency regarding MA prior authorization requirements and their application.
- Provide a pathway for CMS to institute real-time decisions for routinely approved items and services in the future and clarify CMS’ authority to establish timeframes for e-PA requests, including expedited determinations, real-time decisions for routinely approved items and services, and any other PA request.
- Expand beneficiary protections to improve enrollee experiences and outcomes.
- Require HHS and other agencies to report to Congress on program integrity efforts and other measures to further improve the e-PA process.
Over 550 organizations representing patients, clinicians, hospitals, and other key stakeholders in the healthcare industry have endorsed the legislation. S. 1816 currently has 47 cosponsors in the Senate, and H.R. 3514 has 73 cosponsors in the House.
More eyes turn to MEI
MedPAC endorses tying Medicare Physician Reimbursement to the Medicare Economic Index (MEI) and Congress begins to follow suit.
On April 10, the Medicare Payment Advisory Commission (MedPAC) voted unanimously to recommend that Congress replace current law updates to the physician fee 
schedule with an annual change based on a portion of the growth in the Medicare Economic Index, such as MEI minus 1%. MedPAC recommended that Congress consider setting reimbursement in such a manner annually for the foreseeable future. The current baseline increase to physician reimbursement starting with 2026 is 0.25%, or 0.75% for doctors sufficiently participating in advanced alternative payment models.
Providing a yearly reimbursement increase to reflect the growing costs of running a healthcare practice is an approach Medicare uses for other healthcare providers, such as hospitals. The MedPAC recommendation comes as Congress failed to address a 2.83% cut in Medicare Payments for 2025 despite several bipartisan attempts. Physicians have endured five years of payment cuts while other entities, such as Medicare Advantage, have seen increases.
For years, the Alliance of Specialty Medicine has endorsed the concept of an inflationary update tied to the Medical Expenditure Index (MEI) and has supported several bipartisan bills that follow this approach.
In this Congress, the current reconciliation budget package replaces the differential current law payment updates with a physician update of 75% of MEI in 2026 and 10% of MEI in each subsequent year.
Medicaid in Focus
Medical Societies Express Support for Medicaid as Congress Proposes Reforms to the Program
Medical societies representing primary and specialty physicians wrote letters to the bipartisan leadership of the House and Senate to offer their support for Medicaid and register their concerns about the proposed changes being considered by Congress.
In one letter, the organizations highlight Medicaid’s critical role in providing health care to over 80 million Americans, including vulnerable populations such as low-income children, pregnant patients, seniors, and people with disabilities. They argue that the proposed changes—such as altering federal financing, limiting eligibility, shifting costs to states, and increasing administrative complexity—threaten patient care, reduce access to essential services, and exacerbate hospital and practice closures, particularly in rural areas. The signers of the letter emphasized that Medicaid improves health outcomes and saves lives.
Another letter emphasizes the importance of Medicaid, as well as the Children’s Health Insurance Program (CHIP), as essential lifelines for low-income and vulnerable Americans, and raises concerns about Medicaid reform proposals that could disrupt coverage for vulnerable populations by shifting costs to states without ensuring continuity of care.
The letter also acknowledges recent legislative proposals that include positive reforms, such as adjustments to Medicare physician payments and program integrity measures aimed at reducing improper Medicare payments.
Finally, the letter highlights additional reform opportunities, including value-based care models, the expansion of telehealth services, and nutrition-focused strategies to prevent chronic diseases. It also calls for enhanced accountability, transparency, and oversight in Medicaid managed care, citing issues such as high rates of prior authorization denials.
The physician organizations urge Congress to collaborate with frontline healthcare providers to develop bipartisan policies that strengthen Medicaid, improve patient outcomes, and ensure the sustainability of the healthcare system.
The Case For Medicare Payment Reform: A Neurosurgeon’s Perspective
Richard P. Menger, MD, MPA, FAANS, a neurosurgeon and health policy advocate, has emerged as a powerful voice in the national conversation about Medicare payment reform. As a Forbes contributor, Dr. Menger recently published two editorials, “Medicare Is Failing Patients: A New Bill Can Help Fix That” on Feb. 11 and “Physician Pay Cut Again: Can GOP Leadership Save Medicare Access?” on March 11, underscoring the pressing need for legislative action to address declining physician reimbursements and their impact on access to patient care.
In the February editorial, Dr. Menger highlights a concerning 33% decline in Medicare physician reimbursement between 2001 and 2025, when adjusted for inflation. This reduction comes despite significant increases in the cost of running a medical practice, including rent, staff salaries, health insurance for employees, and malpractice premiums. Dr. Menger warns that this downward trend in reimbursement discourages physicians from accepting Medicare patients.
Dr. Menger points to legislative solutions, including a recently proposed bill, the Medicare Patient Access and Practice Stabilization Act (H.R.879). Co-sponsored by Rep. Greg Murphy, MD, (R-N.C.), Rep. Jimmy Panetta (D-Calif.), and eight other House members, the bill aims to reverse the Medicare cut to physician pay and, more importantly, align physician reimbursement with inflation, ensuring continued access to care for Medicare patients.
“Doctors in America are struggling like never before because of ongoing Medicare cuts, and that’s putting millions of seniors at risk of losing access to affordable, quality health care,” Rep. Murphy remarked when quoted for the editorial. The Medicare Patient Access and Practice Stabilization Act represents a critical step toward. By stabilizing physician reimbursement and curbing incentives for unchecked consolidation, this bill safeguards practitioners and the patients they serve.
In Dr. Menger’s March editorial, he calls on GOP leadership in the House of Representatives to address the ongoing physician pay cuts to Medicare. The recent congressional spending package failed to adjust physician reimbursement rates. This comprises a direct 2.8% pay cut and a 3.5% increase in medical inflation, the rising costs of operating a practice, as calculated by the Medicare Economic Index.
“The ripple effects reach beyond physicians, endangering patient care continuity as practices confront closure or consolidation. Rural providers, often in traditionally Republican districts and already operating with limited resources, may disproportionately shoulder this burden, exacerbating healthcare access disparities. The lack of inflationary adjustments in Medicare’s physician fee schedule intensifies this crisis, threatening the program’s sustainability and equity,” states Dr. Menger.
Medicare patients are likely to encounter growing barriers to care as systemic reimbursement disparities persist. Private insurance consistently outpaces Medicare, reimbursing physicians approximately 43% more for identical services.
The payment challenges stem from a reimbursement methodology that fails to account for rising inflation, increasing practice expenses, and the growing complexity of patient care. The current system lacks mechanisms to incentivize quality improvements or innovation, perpetuating financial instability and undermining the sustainability of physician practices. Throughout both articles, Dr. Menger emphasizes that the current trajectory is unsustainable and emphasizes the need to preserve patient access to care.
Specialists Weigh in on Medicare Drug Price Negotiation Program (MDPNP)
In a letter addressed to the Republican leadership of Congress, several specialty medical societies, nursing organizations, and patient groups urged Congress to align the Medicare Drug Price Negotiation Program (MDPNP) eligibility timelines for small-molecule drugs and biologic products at 11 years post-FDA approval. The letter supports the EPIC Act (S.832/H.R.1492), introduced by Sen. Tillis and Rep. Murphy, and the President’s recent Executive Order to eliminate the “pill penalty.”
The disparity in MDPNP eligibility timelines—7 years for small molecule drugs and 11 years for biologic products—has raised concerns about reduced investment in 
research and development for small molecule drugs, which are essential for treating chronic conditions like hypertension and gastrointestinal disorders. The letter emphasizes the importance of both drug types in patient care and self-management, warning that the current policy could negatively impact drug accessibility, affordability, and innovation.
The organizations advocate for parity in MDPNP timelines to support research and development for both drug types, ensuring future cures and better patient outcomes. They urge Congress to include the EPIC Act in their reconciliation package and offer their support in advancing this policy priority.