OPINION:
“You have cancer.” Those three words bring time to a screeching halt. I know; it happened to me. Yet one thing I’m grateful for is that I was diagnosed early and treated quickly none of that would have been possible if my colonoscopy had been denied because of prior authorization.
Prior authorization requires health insurance plan approval before a physician can act on a patient’s next treatment or prescribe medication. For millions of Americans, prior authorization is a nightmare, and it isn’t getting better.
As an emergency room physician, I know that time is one of a medical professional’s most vital resources. You could have a great doctor and a solid treatment plan, and catch the disease at its very first symptom, and still have medical complications because an insurance company denied the prior authorization claim.
The way prior authorization works today adds an extra complication to the time-sensitive decision-making process. Too often, physicians in a different specialty make the final decision. Even worse, an algorithm might be doing it. In a Minnesota lawsuit titled Class Action v. UnitedHealth, insurance policyholders are claiming UnitedHealthcare is using an AI model with a 90% error rate to systematically deny claims to senior citizens.
The plaintiffs argue that UnitedHealth’s AI model, known as “nH Predict,” is incredibly flawed, setting unrealistically optimistic recovery timelines that give UnitedHealthcare the ability to severely curtail benefits. However, given the financial windfall UnitedHealth has enjoyed thanks to nH Predict’s faulty predictions, the plaintiffs are concerned that UnitedHealth has no intention of improving nH Predict’s diagnostic capabilities.
Congress has an obligation to ensure that patients can access the treatment they need and deserve and this means not being denied treatment by an algorithm.
As a physician and survivor of thyroid and colon cancer, my Reducing Medically Unnecessary Delays in Care Act of 2025 serves as a solution to bust through the red tape that often puts health insurance bureaucrats between patients and their doctors. The bill reforms prior authorization in Medicare and Medicare Advantage by requiring board-certified physicians in the same specialty to be the ones making these important decisions. Simply put, if a gastroenterologist deems a colonoscopy necessary due to a history of polyps, you get one. You get treated because a physician, in that specialty, considers it necessary not health plan bureaucrats or an AI program. Screenings like colonoscopies save lives, and delays from insurance companies only place patients at greater risk.
Modern American health care is a maze of bureaucratic hurdles and payment issues. According to the American Medical Association, 23% of physicians report that prior authorization has led to a patient’s hospitalization, while 18% report that it has led to a life-threatening event. In the same 2024 survey, 94% of physicians reported that prior authorization requirements negatively impacted patient care.
Insurance companies are also seeking to expand the procedures requiring prior authorization, meaning patients will need permission from an insurance representative to get coverage for more medical procedures. In a survey conducted by the Alliance of Specialty Medicine, more than 93% of respondents answered that prior authorization has increased for procedures; more than 83% answered that prior authorization has increased for diagnostic tools, such as labs and even basic imaging; and two-thirds (66%) agree that prior authorization has increased for prescription drugs. Physicians have noted that even many generic medications now require preapprovals. Every extra bureaucratic hurdle delays vital care, putting Americans at risk.
Burdening physicians with administrative paperwork, especially during a doctor shortage, exacerbates the challenges faced by Medicare and Medicare Advantage. When 94% of doctors believe that a process is harming patient care, it must be taken seriously.
In the wake of the COVID-19 pandemic, patients want a more active role in their care. This is a golden opportunity to reinforce the doctor-patient relationship, increase patient care satisfaction, and improve treatment quality. We must ensure that the patient remains central to the healthcare decision-making process, with specialists in the same field making the final decisions. If AI has a role to play in future healthcare, it should expand patient access and treatment options, not limit them.
When an expectant mother needs a fetal echocardiogram due to an abnormal ultrasound, or a firefighter requires a knee replacement, they should be able to take comfort knowing their prior authorization reviewer is also a physician of that same specialty. Everyone can agree that an orthopedic surgeon shouldn’t be making decisions about an oncology treatment plan, because their training doesn’t align.
Physicians are trained to make the medical decisions they deem necessary. Patients deserve swift medical care without the red tape. My bill ensures both sides of the stethoscope are taken care of.
• Rep. Mark Green is chairman of the House Homeland Security Committee and serves on the House Foreign Affairs Committee. He is a member of the GOP Doctors Caucus and the Congressional Bipartisan Rural Health Caucus.
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