Congress judges prior authorization by who runs it, not how

Congress judges prior authorization by who runs it, not how. In July 2026, the House Ways and Means Committee voted 42-0 and the Energy and Commerce Committee voted 45-0 to advance the Improving Seniors’ Timely Access to Care Act, which would tighten prior authorization in Medicare Advantage. On July 16, the Senate voted 46-50 against a resolution to end WISeR, the model that brings prior authorization to traditional Medicare in 6 states.

The votes do not contradict each other on their face. The Seniors’ Act targets private plans, and WISeR is an experiment run by CMS’s Innovation Center. Both concern the same practice and the same Medicare beneficiaries, though. The standards Congress would write into law for private plans are largely missing from the model it just kept.

The case made at the end is for a single set of prior authorization standards for Medicare, whoever runs the review.

Key takeaways

• The Seniors’ Act has rare support. As of July 21, 2026, H.R. 3514 had 298 House cosponsors and its Senate companion, S. 1816, had 71. Both House committees of jurisdiction approved it without dissent.
• Most of it is already regulation. Its core requirements appear in CMS’s 2024 interoperability and prior authorization rule. The bill would put them in statute, where a later rule could not remove them.
• Cost stalled it before. The House passed an earlier version by voice vote in 2022, after CBO estimated a cost of $16.2 billion over 10 years.
• The Senate kept WISeR. A resolution to end the model failed 46-50 on July 16. A House appropriations amendment to block its funding is still pending.
• WISeR lacks protections Congress wants for private plans. Its contractors are paid a share of averted spending, and CMS’s provider materials describe no public reporting of their decisions.
• A single rulebook would end the asymmetry. The standards in the Seniors’ Act should apply to prior authorization anywhere in Medicare, including CMS’s own models.

Where the Seniors’ Act stands

The bill has been here before. In September 2022, the House passed an earlier version, H.R. 3173, by voice vote. CBO estimated it would cost $16.2 billion over 10 years, and the bill stalled. Rep. Kevin Brady urged the Senate at the time to “resolve the cost issue,” according to ThinkAdvisor.

Much has changed since then. CMS finalized its interoperability and prior authorization rule in January 2024, and insurers made a voluntary pledge in June 2025 that covers some of the same ground. The 2026 version moved through both House committees of jurisdiction in July.

Compiled from press and association reports. ThinkAdvisor covered the 2022 vote. ASTRO and AAPM&R covered the 2026 committee actions.

The support is unusually broad. AAPM&R counted 298 House and 71 Senate cosponsors as of July 21, and more than 300 national and state organizations have endorsed the bill. The sponsors’ release cited HHS-OIG findings that Medicare Advantage plans ultimately approved 75% of requests they had initially denied.

Why Congress is acting

The numbers behind the bill are familiar. Medicare Advantage insurers made about 52.8 million prior authorization determinations in 2024 and denied 7.7% of them, according to KFF. Only 11.5% of denials were appealed, and 80.7% of appealed denials were overturned. A process in which most appealed denials are reversed, and most denials are never appealed, invites the question of how many of the unappealed ones would also have been reversed.

HHS-OIG asked a version of that question in a 2022 report. It found that 13% of the prior authorization denials it reviewed in Medicare Advantage met Medicare coverage rules and would likely have been approved in traditional Medicare. Those findings are the backbone of the sponsors’ case.

States have acted too. Our reviews of gold card laws and state AI rules described their limits on prior authorization and automated denials. Those laws generally do not reach Medicare Advantage, because federal standards for the program preempt most state insurance rules. For Medicare beneficiaries, Congress and CMS are the only rule makers.

What the bill would require

The bill amends Medicare Advantage law. Its main provisions, as the sponsors describe them, track requirements CMS has already adopted by regulation, with a few additions.

From the sponsors’ release (July 2026) and the CMS fact sheet on CMS-0057-F (January 2024).

Why codify what regulation already requires

Regulations change. In April 2026, CMS’s CY2027 Medicare Advantage rule removed the requirement that plans analyze their prior authorization decisions for health equity, which CMS had finalized in 2024. Our analysis of the CY2027 rule covered that reversal, and our earlier review of the first equity analyses showed what plans had begun to publish. A requirement in statute cannot be removed by the next rulemaking cycle. The same logic applies to voluntary commitments. The insurers’ 2025 pledge carries no penalty if a plan falls short, and a statute would turn parts of it into obligations.

The real-time provision goes further than current rules. CMS’s timeframes set outer limits measured in days. The bill would clarify HHS authority to require real-time answers for services that are routinely approved. Insurers pledged in 2025 to answer 80% of complete electronic approvals in real time in 2027, as our piece on real-time prior authorization described. The bill would let HHS make that kind of target binding.

The cost question

Cost was the obstacle in 2022, and it will shape the bill’s path in the Senate again. The 2022 estimate predates CMS’s 2024 rule. Because many of the bill’s requirements now exist in regulation, a new estimate could look different. Until CBO scores the 2026 bill, its cost is the main unknown. A lower estimate would remove the obstacle that stopped the bill in 2022, and a high one would send the sponsors looking for offsets again.

WISeR and the Senate vote

WISeR, the Wasteful and Inappropriate Service Reduction model, began in January 2026 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. It adds prior authorization in traditional Medicare for a set of services CMS considers vulnerable to misuse, such as epidural steroid injections and skin and tissue substitutes. It is scheduled to run through 2031, according to Becker’s. Our WISeR analysis covered its design when it launched.

The first year’s list covers procedures and products where CMS saw a risk of overuse.

From CMS’s WISeR provider fact sheet.

The model’s mechanics differ from Medicare Advantage in ways that matter.

• Who reviews. Technology companies contracted for each state review requests. CMS’s provider fact sheet says “clinicians employed by these companies will review non-affirmation requests.”
• How they are paid. Participants are “compensated based on a share of averted expenditures rather than on a fixed fee or per-claim basis.” Payments are adjusted for performance measures that include timeliness and accuracy.
• What providers can choose. A provider can submit a prior authorization request or accept a review after the service and before payment.
• Appeals. CMS says the model makes “no change in provider payments or providers’ appeal rights.”

In July 2026, CMS began an exemption program for providers with high approval rates. A provider must submit at least 10 requests, and the affirmation threshold a participant uses “must be set at 90% or less.” Exemptions apply at the level of an individual clinician’s NPI and last at least a year. Our review of state gold card laws describes similar programs in private coverage.

The vote

In May 2026, GAO determined that WISeR qualifies as a rule subject to the Congressional Review Act, which opened the way for a vote. The act lets Congress overturn an agency rule with a joint resolution, which the president must sign. On July 16, the Senate voted 46-50, along party lines, against the resolution to end it, according to Healthcare Dive. Sen. Ron Wyden said seniors in the 6 states were finding recommended care “slowed or halted by a shadowy, AI-driven third party.” Sen. Mike Crapo said ending the pilot “prematurely will deprive CMS of a useful tool.”

The model still faces the appropriations process. In June, a House Appropriations panel unanimously approved an amendment to the 2027 HHS spending bill that would block funds for implementing WISeR, according to Healthcare Dive.

The case for the model

WISeR’s targets are not arbitrary. Skin substitutes were the center of the largest case in DOJ’s 2026 fraud takedown, in which providers billed Medicare more than $4 billion for a single company’s products, as our takedown analysis described. Traditional Medicare has few tools to stop spending on a service before it is paid. A review before payment is one of them. The model also lets a provider skip prior authorization and accept a review before payment instead, which keeps the service available while the claim is checked.

The objections are not about whether review should exist. They concern how the reviewer is paid and how little of the result the public can see.

The asymmetry

Set side by side, the 2 forms of Medicare prior authorization answer to different rules.

From the sources cited in this analysis. The table describes requirements as written, not how they work in practice.

A prior authorization standard worth writing into law is worth applying to Medicare’s own experiments.

Neither column is a model of perfection. The Medicare Advantage column describes rules, and our reviews of the first public metrics found that the postings vary widely in what they show. The WISeR column describes a model in its first year, run by contractors whose work CMS can change by contract rather than by rulemaking.

Appeals also follow different paths. A Medicare Advantage denial can be appealed to the plan and then to an independent reviewer. A non-affirmation in WISeR is not itself a payment denial. If the service is performed and billed, a denied claim follows traditional Medicare’s appeal process through the claims contractor. Both paths exist, but they differ in speed and in what the patient sees first.

The asymmetry runs both ways. Medicare Advantage plans face more transparency rules, but their financial stake in denials is built into capitation. WISeR’s contractors face fewer public rules, and their stake is explicit in their payment. Neither arrangement removes the incentive to say no. The difference is how much the public can see of the result.

A single rulebook for Medicare

Congress could fix the asymmetry by writing the Seniors’ Act’s principles as standards for prior authorization in Medicare, wherever it happens. CMS could also adopt most of them for WISeR on its own.

1. Publish the same metrics. WISeR participants would post what Medicare Advantage plans post, by service and by state. That means request volumes and decision times, along with how often requests are affirmed and how often appeals reverse a non-affirmation.
2. Answer routine requests in real time. The model’s participants were chosen for their technology. A real-time target for approvals would test that claim in public.
3. Keep a clinician on every no. WISeR already routes non-affirmations to clinicians. Writing that rule into statute for both programs would protect it from change.
4. Tie pay to accuracy, not only to averted spending. A reviewer paid for spending it prevents has a reason to say no. Payment adjustments for accuracy exist in WISeR already. Measuring accuracy by how often decisions are overturned on appeal, and publishing it, would make the adjustment visible.
5. Share an exemption floor. WISeR’s exemption program sets a ceiling of 90% on the approval threshold. A common floor for exemption programs across Medicare would give clinicians the same path in both programs.

Congress has a simple way to do this. The Seniors’ Act could include a section applying its standards to any prior authorization program in Medicare Parts A and B, including demonstrations. CMS would then carry the same obligations whether a plan or a contractor made the decision. The cost of that section would likely be small, because it would add reporting and review standards rather than new coverage.

There are fair objections. WISeR is a demonstration, and the Innovation Center’s purpose is to test designs that existing rules do not allow. Adding every Medicare Advantage rule could blur what the model is testing. Reporting also costs money, and fraud prevention sometimes depends on reviewers not announcing what they look for. Those arguments support tailoring the rules, not exempting the model from transparency. A demonstration that publishes its results teaches more than one that does not.

Where Redlake stands

Redlake builds tools that health plans use in utilization review. A clinician makes every denial, so a machine can say yes, but only a person can say no. Every recommendation shows its reasons, and every decision can be reconstructed.

Those rules do not depend on who pays for the review. They apply the same way to a Medicare Advantage plan and to a contractor reviewing traditional Medicare claims. We think Congress should take the same view. The Seniors’ Act is a sound bill, and its principles would serve beneficiaries in traditional Medicare as well as they serve those in private plans.

That view has a practical side for us. A tool that helps a reviewer decide should show the same reasons and keep the same records in either program. When the rules differ by program, reviewers and the clinicians who send requests have to learn 2 systems for the same decision. Errors follow the seams.

We also think reviewer compensation should never depend on the number of denials alone. The better measure is accuracy, judged by how decisions hold up on appeal. It protects patients and payers at the same time.

What to watch in the rest of 2026

• A House floor vote. With both committees done, the Seniors’ Act is ready for the floor. Watch for a new CBO estimate, which will shape its prospects in the Senate.
• Senate action on S. 1816. With 71 cosponsors, the Senate bill has broad support. Watch whether the Finance Committee takes it up and how it handles cost.
• Appropriations. Watch whether the House amendment blocking WISeR funds survives the full appropriations process.
• Drug prior authorization. CMS’s April 2026 proposal would extend its prior authorization rules to drugs in several programs. Watch whether Congress treats drug and service reviews alike in the Seniors’ Act.
• WISeR data. Watch for any CMS release of affirmation rates and decision times from the model’s first year.

About this analysis

Method. The sources are the legislative record of the Improving Seniors’ Timely Access to Care Act and the Senate vote on WISeR, read against CMS’s 2024 rule and CMS’s published materials on WISeR.

Data notes. Cosponsor counts are as AAPM&R reported them on July 21, 2026. Bill provisions are described from the sponsors’ release, not from the bill text. WISeR details come from CMS fact sheets and press coverage. The comparison table describes requirements as written. The single-rulebook proposal is this analysis’s suggestion.

Sources. Office of Rep. Mike Kelly, press release (July 2026). AAPM&R (July 2026). ASTRO (July 2026). ThinkAdvisor (September 2022). CMS, CMS-0057-F fact sheet (January 2024). CMS, WISeR provider and exemption program fact sheets. Becker’s Payer Issues (May 2026). Healthcare Dive (July 2026).

Frequently asked questions

What is the Improving Seniors’ Timely Access to Care Act?

It is a bipartisan bill, H.R. 3514 in the House and S. 1816 in the Senate, that would set statutory standards for prior authorization in Medicare Advantage. Its provisions include an electronic prior authorization process and real-time decisions for routinely approved services. It would also require reporting on how plans use prior authorization.

Did the Seniors’ Act pass Congress in 2026?

It had cleared the House Ways and Means Committee 42-0 and the Energy and Commerce Committee 45-0 by July 23, 2026. It had not received a floor vote in either chamber.

What happened to the effort to repeal WISeR?

On July 16, 2026, the Senate voted 46-50 against a Congressional Review Act resolution to end the model. A House appropriations amendment to block funding for WISeR was still pending.

Why did the Seniors’ Act stall in 2022?

The House passed it by voice vote in September 2022, but CBO estimated a cost of $16.2 billion over 10 years. Without an offset for that cost, the bill did not advance in the Senate.

Who reviews WISeR prior authorization requests?

Technology companies contracted by CMS for each of the 6 states review the requests. According to CMS, clinicians employed by those companies review requests that are not affirmed. The companies are paid a share of averted expenditures, adjusted for performance measures.

Does the Seniors’ Act apply to WISeR?

No. The bill amends Medicare Advantage law. WISeR operates in traditional Medicare under CMS’s Innovation Center, so the bill’s standards would not reach it.