Medicare cracks down on insurers' deny-then-reverse prior authorization games

What it does

This bill requires Medicare Advantage plans to reverse (overturn) prior authorization denials at a rate no higher than 25% when beneficiaries appeal or request reconsideration. If a plan exceeds this threshold or significantly reduces its reversal rate year-over-year without good cause, the federal government can terminate the plan's contract. The bill aims to prevent Medicare Advantage insurers from systematically denying coverage upfront and then reversing those denials on appeal—a pattern that may delay care and burden beneficiaries.

Why we flagged it

The bill's operative mechanism is a regulatory enforcement standard—a reversal-rate cap with contract termination as the remedy. It is not a subsidy, tax carve-out, or deregulation; it is a consumer-protection rule that restrains insurer behavior and empowers federal oversight.

What the text implies

• Plans may respond by tightening initial approval criteria to reduce reversals, shifting the burden from appeal-stage reversal to upfront denial—potentially reducing measured reversal rates while worsening initial access.
• The 25% threshold is a bright-line rule; plans near the threshold may face incentive to deny borderline cases upfront rather than approve-then-reconsider, changing the distribution of denials across the approval process.
• Enforcement depends on Secretary's monitoring and contract-termination authority; effectiveness hinges on CMS's capacity to audit reversal rates across thousands of plans and willingness to terminate contracts, which may be politically or operationally constrained.
• The bill does not address the underlying incentive structure (capitated payment) that may drive prior authorization as a cost-control tool; it addresses only the reversal-rate symptom, not the root cause.

Section numbers refer to the bill text the analysis read — linked under Primary records below.

Who it affects

Medicare beneficiaries enrolled in Advantage plans gain a concrete protection: insurers can no longer systematically deny coverage upfront knowing they will reverse on appeal, which delays care and burdens patients. The 25% reversal-rate cap and contract-termination enforcement create accountability for plans that use prior authorization as a delay tactic rather than a legitimate coverage tool.

Named in the bill

Medicare Advantage plans, Centers for Medicare & Medicaid Services (CMS), Social Security Act § 1857, Social Security Act § 1852(g)(2), Social Security Act § 1852(g)(5)

Where it stands

18 cosponsors: 18 Democrats.

• Nov 18, 2025 — Introduced · Congress.gov: “Introduced in House”
• Nov 18, 2025 — Referred to House Committee on Energy and Commerce and House Committee on Ways and Means · Congress.gov: “Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a…”

Dates and quoted wording are Congress.gov's action record; the timeline shows status changes, not every procedural step.

Money around this bill

2 lobbying clients named this bill on 2 disclosure filings across 1 quarter, Dec 2025 to Dec 2025. Those filings disclosed $40,000 in lobbying spend. A filing names 18 bills on average, so that figure is what each filing reported, not a share belonging to this bill.

More lobbying clients named this bill than 41% of bills with at least one filing.

Mark Pocan, the sponsor, reported $474,320 in PAC receipts in the 2026 cycle.

• Center for Health and Democracy — $20,000 on 1 filing
• Social Security Works — $20,000 on 1 filing

Lobbying Disclosure Act filings through Jan 16, 2026. A filing shows who paid to lobby on a bill it names, not what changed.