Prior Authorization Accountability Act
- Sponsor
- Rep. Goldman, Craig A. [R-TX-12]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Jun 25, 2026
Bottom line
The bill aims to significantly increase transparency in prior authorization processes by requiring health plans and insurers to publicly report comprehensive data on their decisions and use of technology, empowering consumers and enhancing regulatory oversight.
What it actually does
This bill mandates that group health plans and health insurance issuers publicly disclose detailed data regarding their prior authorization practices, including approval and denial rates, appeal outcomes, processing times, and the use of artificial intelligence or other technologies in decision-making. These requirements are implemented by amending the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986. Additionally, the bill requires health insurance Exchanges established under the Affordable Care Act to include this prior authorization data in their comparative information for qualified health plans.
Proponents argue
Supporters argue this legislation will bring much-needed transparency to the opaque prior authorization process, which often delays or denies necessary medical care. They contend that public disclosure of denial rates and processing times will empower patients to make more informed healthcare choices, hold insurers accountable for their practices, and shed light on the increasing role of artificial intelligence in healthcare decisions, ultimately improving patient access and outcomes.
Opponents contend
Opponents might argue that the extensive and granular reporting requirements impose significant administrative burdens and compliance costs on health plans and issuers, which could ultimately be passed on to consumers through higher premiums. They may also contend that raw denial rate data without sufficient context could be misleading to consumers and that the bill overregulates an already complex and highly regulated industry.
The bill is concise and clearly structured, allowing an informed reader to grasp its core provisions and implications within a reasonable timeframe.
Section 2(a), adding new section 2799A-12 to the Public Health Service Act
Mandated Public Disclosure of Prior Authorization Data for Health Plans and Issuers
This provision requires group health plans and health insurance issuers to collect and publicly report detailed data on their prior authorization practices, starting January 1, 2027. This includes a list of services requiring prior authorization, the percentage and number of initial approvals and denials, the number of appeals, appeal outcomes, average and median processing times, and information on the use of artificial intelligence or other technologies in making prior authorization decisions. This data must be submitted to the Secretary of HHS and made available on the plan's or issuer's public website.
Supporters argue
Supporters argue this provision is crucial for shedding light on opaque prior authorization processes, which often delay or deny necessary care. They contend that public data will drive competition among insurers to improve their practices and provide patients with tools to advocate for themselves, ultimately leading to better patient outcomes.
Critics contend
Opponents may argue that the detailed reporting requirements are overly prescriptive and burdensome, requiring significant IT system changes and staff time. They contend these increased administrative costs will ultimately be passed on to consumers through higher premiums, without a clear benefit proportional to the expense.
Tradeoffs
This provision balances the desire for greater transparency and consumer protection against the administrative and financial burden placed on health plans and issuers for extensive data collection and reporting.
Section 2(b), adding new section 727 to the Employee Retirement Income Security Act of 1974
Extension of Transparency Requirements to ERISA-Governed Plans
This section extends the same detailed prior authorization transparency requirements to group health plans and health insurance issuers offering group health insurance coverage under the Employee Retirement Income Security Act of 1974 (ERISA). This ensures that self-funded employer plans, which are typically governed by ERISA, are also subject to the new mandates for data collection and public reporting.
Section 2(c), adding new section 9827 to the Internal Revenue Code of 1986
Internal Revenue Code Enforcement of Transparency Requirements
This section reinforces the prior authorization transparency requirements by amending the Internal Revenue Code of 1986. This typically means that non-compliance with the data collection and reporting mandates could result in excise taxes or other financial penalties, providing an additional and strong enforcement mechanism for the new federal requirements.
Section 3, amending Section 1311(d)(4)(C) of the Patient Protection and Affordable Care Act
Integration of Prior Authorization Data into ACA Exchange Comparability Tools
This section mandates that, beginning January 1, 2029, health insurance Exchanges established under the Affordable Care Act (ACA) must include the newly required prior authorization transparency data (submitted under the Public Health Service Act) as part of the comparative information displayed for qualified health plans. This will allow consumers to directly compare health plans based on their prior authorization practices when enrolling through an Exchange.
Requires reporting on the percentage of prior authorization requests approved or denied 'solely through the utilization of decision support technology, artificial intelligence technology, machine-learning technology, clinical decision-making technology, or any other technology specified by the Secretary,' and mandates a disclosure and description of any such technology utilized.
Section 2(a)(6) and (7) (and parallel sections in ERISA and IRC amendments)
Why it matters:This is standard legislative practice to include specific technological considerations within broader regulatory frameworks, ensuring future-proofing and addressing emerging practices. It's not necessarily evasive, but rather comprehensive in its scope.
Case for: Proponents argue this is a forward-looking and critical provision to ensure transparency and accountability as health plans increasingly adopt AI and automated systems for prior authorization. It allows for scrutiny of algorithmic bias, fairness, and the potential for 'black box' decision-making in healthcare.
Case against: Opponents might argue that requiring detailed disclosure of proprietary technology could stifle innovation or reveal trade secrets, and that the definition of decisions made 'solely through' technology might be difficult to audit or enforce in practice, leading to compliance challenges.
Estimated impact: This provision will significantly impact how health plans develop, deploy, and disclose automated decision-making tools for prior authorization, potentially leading to more human oversight, more transparent algorithmic design, and increased scrutiny from regulators and the public.