By Chris Myers, CEO of No Surprise Bill
There’s a growing concern inside CMS—and on the front lines of healthcare delivery—that large national insurers are treating Medicare Advantage (MA) claims with the same aggressive tactics they use in commercial markets. And finally, it seems CMS is taking notice.
According to a new report, CMS is exploring ways to limit how insurers use prior authorization in Medicare Advantage plans. The proposed changes would aim to streamline the process and reduce delays in patient care—delays that all too often result from insurers putting up roadblocks to medically necessary services.
The Same Old Playbook, Now in Medicare
Let’s be clear: prior authorization was never meant to be a profit strategy. But that’s exactly what it’s become—particularly in Medicare Advantage, where the incentive for insurers to underpay or delay payment is strong and largely unchecked.
MA plans have been marketed as more efficient, more patient-centered alternatives to traditional Medicare. But behind the scenes, they’re using the same denial-and-delay tactics familiar to any provider who’s dealt with commercial payers. The only difference? Seniors are now the ones paying the price.
CMS Steps In—But Will It Be Enough?
While CMS has been slow to act, it is now considering changes that could:
- Reduce the number of procedures requiring prior authorization .
- Standardize rules across plans
- Automate decisions to speed up care approvals
But there’s still no guarantee these changes will be mandatory. Insurers, unsurprisingly, are pushing for a voluntary approach—one that would allow them to “self-regulate.” We’ve seen how that ends.
A System Designed to Exhaust
The appeal process for denied claims—already exhausting and expensive—is especially hard for elderly patients and the providers who care for them. As I’ve said before, bureaucracy is the real gatekeeper of care in today’s system. And in Medicare Advantage, that bureaucracy is increasingly designed not to protect patients, but to protect insurer profit margins.
The American Medical Association, among others, is applauding CMS’s new urgency, as are many providers who’ve long struggled with endless paperwork, arbitrary denials, and AI-driven decision-making with little clinical oversight.
This Is the Moment
We’ve reached a tipping point. When CMS Administrator Mehmet Oz publicly acknowledges that there are thousands of procedures burdened by prior authorization, and that AI and automation could streamline the process, it means regulators are finally catching up to what providers have known all along.
Medicare Advantage is too important a program to be compromised by commercial-style denial tactics. If CMS wants to show leadership, it must move beyond talk. We need enforceable rules, meaningful oversight, and real consequences for insurers who prioritize profits over patients.
At No Surprise Bill, we’ll keep holding the system accountable—because fairness in healthcare shouldn’t depend on who your insurance company is.
Until next time,
Chris Myers
