Congressional Opposition Mounts Against CMS Medicare Prior Authorization Expansion

Congresswoman Maggie Goodlander, joined by 40 congressional colleagues, has formally requested the Centers for Medicare & Medicaid Services (CMS) to pause the implementation of a proposed Medicare prior authorization model scheduled for January 1, 2026. This model proposes expanded use of prior authorization in Traditional Medicare, where for-profit companies would play a role in approving healthcare services before providers deliver them. The lawmakers expressed concern that this approach might lead to increased denials of care and a potential decline in the quality of patient services.

The proposed prior authorization model targets providers across selected states and aims to control costs by introducing external oversight into healthcare decisions. However, critics, including Goodlander, argue that prioritizing profit through such intermediaries could undermine patient care. They advocate instead for focusing on resolving current challenges within Medicare Advantage programs rather than expanding administrative burdens in Traditional Medicare.

Another significant point raised in their correspondence to CMS Administrator Dr. Mehmet Oz is the intended use of artificial intelligence (AI) to assist or make medical necessity determinations. The lawmakers warn that reliance on AI could further restrict patient access to necessary healthcare services due to the risk of inaccurate or overly restrictive decisions.

This proposed change has important implications for healthcare providers, payers, and patients in the Medicare system. From a regulatory perspective, expanding prior authorization requirements shifts the compliance landscape and may increase administrative costs and workflow complexity for healthcare providers. For payers and regulators, balancing cost containment with maintaining patient access and care quality remains a core challenge.

Stakeholders in the insurance and healthcare sectors should monitor CMS's response and the ultimate decision regarding the prior authorization model. The debate highlights ongoing tensions between cost management strategies and the delivery of patient-centered care in Medicare. The discussion also underscores the evolving role of technology, such as AI, in regulatory decision-making within healthcare programs.