Reducing Medically Unnecessary Delays in Care Act of 2025

This bill aims to reform prior authorization processes within the Medicare program by mandating that all preauthorization and adverse determination decisions for Medicare services be made by qualified physicians . It applies to Medicare administrative contractors, Medicare Advantage plans, and prescription drug plans, requiring them to comply with new standards for medical decision-making. Under the proposed law, physicians making these determinations must possess a current, valid, non-restricted license and be board-certified or eligible in the same specialty as the health care provider managing the condition. All restrictions and determinations must be based on medical necessity and appropriateness, guided by written clinical criteria. These clinical criteria must be evidence-based, nationally recognized, reflect community standards of care, and ensure quality and access to needed services. Plans are required to obtain input from actively practicing, non-employee physicians when establishing or substantially altering these criteria, which must also be evaluated and updated annually. Furthermore, the legislation enhances transparency by requiring plans to post all current preauthorization requirements, restrictions, and clinical criteria on their websites in easily understandable language. Plans must also provide contracted health care providers with 60 days' written notice before implementing new or amended requirements and make statistics on preauthorization approvals and denials publicly available, categorized by specialty, medication/procedure, indication, and reason for denial.