Bipartisan Bill Targets Prior Authorization and Payment Practices in Medicare Advantage

The bill would impose new utilization management standards, including 72-hour turnaround times for standard prior authorization requests, 24-hour timelines for expedited prior authorization requests and appeals, and real-time determinations for certain routine services. The bill would also prohibit MA plans from applying coverage criteria that are more restrictive than traditional Medicare, and would bar retroactive payment denials following prior authorization approval. Additional provisions would require timely payment of claims, mandate that medical necessity determinations be made by appropriately qualified clinicians, and establish a compliance and accountability framework that ties financial penalties and public reporting to a plan’s authorization and claims practices.

Click Here to read the entire June 2026 Healthcare Law Update now!