Prior Authorization Accountability Act

**Summary of H.R. 9396 – Prior Authorization Accountability Act**

**1. Main Purpose & Objectives** The primary objective of H.R. 9396 is to increase transparency in health insurance prior authorization practices by mandating the public disclosure of claim denial rates and related metrics. The bill seeks to expose inefficiencies and potential abuses in utilization management—particularly the use of automated decision-making systems—by requiring insurers and group health plans to report detailed data on prior authorization requests, including approval/denial rates, appeal outcomes, processing times, and technology use. While framed as a consumer protection measure, the underlying intent is to create market pressure through information asymmetry reduction, enabling employers, patients, and competitors to assess insurer performance and potentially shift toward more efficient, less restrictive coverage models.

**2. Key Provisions & Changes to Existing Law** The bill amends three major statutes: - **Public Health Service Act (PHSA)**: Adds Section 2799A-12 under Title XXVII, requiring group and individual health insurers (including those on ACA Exchanges) to submit and publish prior authorization data to HHS and on public websites. - **ERISA**: Adds Section 727 under Subpart B of Part 7 of Title I, extending identical reporting requirements to employer-sponsored group health plans. - **Internal Revenue Code**: Implied conformity through cross-referencing, ensuring tax-advantaged plans comply.

Required disclosures include: - List of services subject to prior authorization - Approval/denial rates (aggregate and by service) - Appeal volumes and outcomes (by level, including judicial review) - Average and median processing times (in hours) - Use and description of AI/ML or algorithmic decision-support tools in denials/approvals

Data must be reported annually for plan years beginning on or after January 1, 2027, with formatting and aggregation standards to be determined by the Secretary of HHS.

**3. Affected Parties & Stakeholders** - **Health Insurance Issuers**: Face increased compliance costs, reputational risk, and potential pressure to reform restrictive prior authorization protocols, especially if denial rates or AI-driven denials are exposed as excessive. - **Group Health Plans (Employers)**: Must ensure compliance if self-insured; gain leverage to negotiate better terms with insurers or consider alternatives like reference-based pricing or direct contracting. - **Patients & Providers**: Benefit from greater transparency, enabling informed plan selection and reducing administrative burden from opaque denials. - **HHS & State Exchanges**: Gain regulatory oversight tools and data for enforcement and policy refinement. - **Technology Vendors**: May face scrutiny over proprietary algorithms used in utilization management, potentially spurring demand for explainable AI or third-party auditing.

**4. Potential Impact & Implications** The bill introduces a form of market discipline through transparency—a mechanism favored by libertarian-leaning reformers who distrust bureaucratic oversight but believe in the power of information to drive efficiency. By forcing disclosure of denial rates and AI use, the bill could accelerate innovation in utilization management, incentivizing insurers to adopt more accurate, evidence-based systems to avoid public backlash or employer defection.

However, compliance will impose administrative burdens, particularly on smaller insurers. Long-term, this could accelerate consolidation in the insurance market as scale becomes necessary to manage regulatory complexity—a trend that may ultimately benefit large, vertically integrated players.

While not a direct cost-containment measure, the bill undermines the opacity that enables inefficient or overly restrictive prior authorization practices. In the hands of informed employers and consumers, this data could catalyze a shift toward value-based insurance design and reduce wasteful administrative spending—aligning, paradoxically, with the self-interest of large employers and sophisticated purchasers who seek to minimize total cost of risk without sacrificing access to care.

Ultimately, H.R. 9396 represents a technocratic, market-oriented approach to healthcare reform: less command-and-control, more disclosure-driven accountability—precisely the kind of mechanism that appeals to those who view government not as a provider of solutions, but as a catalyst for private-sector efficiency.

Main Purpose & Objectives: This bill aims to increase transparency in health insurance prior authorization practices by requiring insurers and group health plans to publicly disclose detailed data about their claim denial rates, approval timelines, and use of automated decision-making systems. The core objective is to hold insurers accountable for potentially excessive or opaque prior authorization requirements that delay or deny medically necessary care.

Key Provisions & Changes to Existing Law: The bill amends three major federal statutes: Title XXVII of the Public Health Service Act (PHSA), the Employee Retirement Income Security Act of 1974 (ERISA), and the Internal Revenue Code. It adds new transparency requirements mandating that health plans and insurers subject to prior authorization rules must: - Publish a list of all services requiring prior authorization - Report approval and denial rates (aggregate and by service type) - Track denied claims that are appealed and the outcomes of those appeals - Disclose average and median processing times for authorization requests - Report how often denials or approvals are made using AI, machine learning, or other automated technologies - Describe the specific technologies used in decision-making These disclosures must be made available on public websites and submitted to federal agencies (HHS, DOL, Treasury) and, where applicable, health insurance Exchanges, starting for plan years beginning January 1, 2027.

Affected Parties & Stakeholders: The requirements apply to group health plans and health insurance issuers offering group or individual coverage that impose prior authorization requirements. This includes private insurers, self-funded employer plans (via ERISA), and plans sold through Affordable Care Act Exchanges. Patients and providers stand to benefit from increased transparency, while insurers face new administrative burdens and potential reputational or regulatory scrutiny based on their reported data. Federal agencies (HHS, DOL, IRS) gain oversight authority to specify timing, format, and aggregation standards for the disclosures.

Potential Impact & Implications: If enacted, this bill could significantly increase accountability in utilization management practices by making denial patterns and algorithmic decision-making visible to the public, regulators, and researchers. It may discourage overly restrictive prior authorization policies by exposing high denial rates or excessive reliance on automated systems. Over time, the data could inform policy reforms, support appeals processes, and reduce administrative waste. However, critics might argue it adds compliance costs without directly limiting insurers’ authority to manage utilization. Ultimately, the bill reflects a growing congressional effort to address patient access barriers through transparency rather than direct regulation of clinical judgment.

**Conspiracy Theorist Uncle’s Breakdown of HR 9396: The Prior Authorization Accountability Act**

Alright, folks, gather ’round the turkey and stuffing—let’s talk about HR 9396, the so-called *Prior Authorization Accountability Act*. Sounds harmless, right? Just making insurance companies show how often they say “no” to your doctor’s requests. But let me tell you—this ain’t about transparency. This is about *control*, and who’s really pulling the strings behind the white coats and algorithmic curtains.

**Main Purpose & Objectives** On the surface, this bill wants to force health insurers and group health plans to publish their prior authorization denial rates—yeah, those annoying hoops your doctor has to jump through just to get you an MRI or a specialty drug. They’d have to spill the beans on how many requests get denied, how long it takes, how many get appealed and overturned, and even whether AI or “decision support technology” (read: Skynet in a server farm) is making the calls. The goal? To shame insurers into approving more care by making their denial rates public. Noble? Maybe. But why now? And why *this* level of detail?

**Key Provisions & Changes to Existing Law** HR 9396 amends three big laws: the Public Health Service Act (for exchange plans), ERISA (for employer-based plans), and the Internal Revenue Code (to tie tax benefits to compliance). Starting in 2027, any plan using prior auth must publish: - A full list of services requiring auth - Approval/denial rates (overall and by service) - Appeal stats and outcomes - Timing of decisions (avg. and median hours) - **How much AI/machine learning is used**—and a description of that tech This isn’t just reporting—it’s algorithmic auditing. And who defines “appropriate manner” of publication? The Secretary of HHS. Unelected bureaucrats deciding how your insurer must confess its sins.

**Affected Parties & Stakeholders** - **Insurers**: Forced to expose internal metrics—could lead to lawsuits, reputational damage, or pressure to approve more care (costing them $$$). - **Employers**: If they self-insure, they’re on the hook for compliance. Hello, new HR burden. - **Patients**: Supposedly benefit from fewer denials and faster care—but what if the data gets spun? What if “transparency” just leads to more bureaucratic delays as companies lawyer up? - **Tech Vendors**: The ones selling AI denial engines? Suddenly under the microscope. Bet they’re lobbying hard behind the scenes. - **Government**: Gains unprecedented insight into how care is rationed—potentially a backdoor to price controls or utilization mandates.

**Potential Impact & Implications** Look, I’m not saying transparency is bad. But when the feds start demanding insurers reveal how their AI denies grandma’s pain meds? That’s not oversight—that’s *preparation*. Preparation for what? A future where the government doesn’t just *watch* the algorithms… it *replaces* them. This bill could be a Trojan horse. Once they have the data, they’ll say, “See? Insurers are too greedy. We need a public option.” Or worse: “The AI is biased—let *us* run it.” And let’s not ignore the timing: 2027. Post-election. When the real agenda kicks in. So yeah, call it accountability. I call it surveillance with a smiley face. Stay skeptical. And pass the gravy.

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**Summary of H.R. 9396 – Prior Authorization Accountability Act**

**1. Main Purpose & Objectives** The Prior Authorization Accountability Act aims to increase transparency in health insurance prior authorization practices by requiring health plans and insurers to publicly disclose detailed data on claim denials, approvals, appeals, and processing times. The bill seeks to empower patients and providers with information to challenge arbitrary or excessive denials, curb abusive utilization management tactics, and hold insurers accountable—particularly those using automated or AI-driven systems to make coverage decisions. Proponents argue this will reduce administrative burdens, improve access to care, and combat what they describe as a profit-driven denial culture among insurance "elites."

**2. Key Provisions & Changes to Existing Law** The bill amends three major federal statutes: - **Public Health Service Act (PHSA)**: Adds Section 2799A-12, mandating that group and individual health plans (including those on ACA Exchanges) submit and publish prior authorization data. - **Employee Retirement Income Security Act (ERISA)**: Adds Section 727, extending identical reporting requirements to employer-sponsored group health plans. - **Internal Revenue Code**: Implicitly affected through conforming changes to tax-preferred health plans, ensuring consistency across regulatory frameworks.

Required disclosures include: - Lists of services subject to prior authorization - Approval and denial rates (aggregate and by service) - Appeal volumes and outcomes (including judicial review) - Average and median processing times (in hours) - Use and description of AI, machine learning, or decision-support technology in denials

Data must be submitted to HHS and posted on plan websites, with potential for aggregate reporting across markets or sponsors.

**3. Affected Parties & Stakeholders** - **Health Insurance Issuers**: Must build reporting infrastructure, potentially exposing high denial rates or overreliance on automated systems. - **Group Health Plans (Employers)**: Face administrative burdens but may gain leverage to negotiate better terms with insurers. - **Patients & Providers**: Gain tools to contest denials, identify patterns of delay or obstruction, and advocate for timely care. - **HHS & State Exchanges**: Tasked with specifying reporting formats and enforcing compliance. - **Technology Vendors**: May face scrutiny if AI tools are shown to drive inappropriate denials.

**4. Potential Impact & Implications** If enacted, the bill could significantly shift dynamics in utilization management. Public exposure of denial rates—especially those driven by AI—may deter insurers from using opaque algorithms to delay or deny care, reducing what critics call "delay, deny, defend" tactics. Providers could use the data to challenge unjust denials, potentially lowering administrative waste and improving patient outcomes. However, insurers may argue the mandate imposes costly compliance burdens and risks misinterpretation of complex clinical data.

Politically, the bill frames transparency as a populist check on corporate power—appealing to bipartisan frustration with insurance bureaucracy while allowing sponsors to position themselves as champions of "freedom" from elitist, profit-driven denial schemes. Whether it leads to meaningful reform or becomes another performative gesture in the health care wars remains to be seen—but the stage is set for a showdown over who really controls access to care: patients, doctors, or the algorithms in the back office.

**Summary of H.R. 9396 – Prior Authorization Accountability Act**

**1. Main Purpose & Objectives** The Prior Authorization Accountability Act aims to increase transparency in health insurance prior authorization practices by requiring health plans and insurers to publicly disclose detailed data on claim denials, approvals, appeals, and processing times. The bill seeks to address concerns about opaque and potentially abusive prior authorization processes that can delay or deny medically necessary care, thereby promoting accountability, informed consumer choice, and oversight by regulators and the public.

**2. Key Provisions & Changes to Existing Law** The bill amends three major federal statutes: - **Title XXVII of the Public Health Service Act (PHSA)** – Adds a new section (2799A-12) requiring group health plans and health insurance issuers (including those offering coverage through Affordable Care Act Exchanges) to submit and publish prior authorization data. - **Employee Retirement Income Security Act of 1974 (ERISA)** – Adds a corresponding section (727) applying the same requirements to employer-sponsored group health plans. - **Internal Revenue Code of 1986** – Implicitly applies the requirements to self-insured plans and other arrangements through cross-references in ERISA and PHSA, ensuring broad coverage.

Starting for plan years beginning on or after January 1, 2027, plans and issuers must annually disclose: - A list of all services subject to prior authorization. - Approval and denial rates (aggregate and by service type). - Data on appealed denials and appeal outcomes (including judicial review). - Average and median processing times (in hours), excluding incomplete submissions. - Use and description of automated decision-making tools (e.g., AI, algorithms) in denials or approvals. Information must be submitted to the Secretary of Health and Human Services (HHS) and posted on a public website, with potential for aggregate reporting across plans or markets as determined by the Secretary.

**3. Affected Parties & Stakeholders** - **Health Insurance Issuers** (including commercial insurers, Medicaid managed care plans offering Exchange coverage, and self-funded plan administrators): Must collect, report, and publish detailed prior authorization metrics. - **Group Health Plans** (both fully insured and self-insured): Subject to the same disclosure requirements under ERISA and PHSA. - **Patients and Providers**: Gain access to transparency tools that may help identify patterns of delay or denial, support appeals, and inform plan selection. - **HHS and State Insurance Regulators**: Receive standardized data for oversight, enforcement, and policy evaluation. - **Technology Vendors**: May face increased scrutiny regarding the use of AI and algorithmic tools in coverage decisions.

**4. Potential Impact & Implications** The bill could significantly reduce administrative opacity in prior authorization, a process frequently criticized by providers and patients for causing treatment delays and contributing to clinician burnout. By mandating public reporting, the legislation may incentivize plans to improve approval rates, streamline processes, and reduce reliance on overly restrictive automated systems. Increased transparency could also empower employers and consumers to compare plans based on administrative efficiency and fairness. However, compliance may impose new administrative burdens, particularly on smaller plans. Critics may argue that public disclosure alone does not address substantive coverage denials or require reform of underlying medical necessity criteria. Supporters view the bill as a critical first step toward accountability in utilization management practices. If enacted, the law could influence future reforms, including potential caps on prior authorization use or stricter standards for automated decision-making in health care.

Alright, let’s break this down like we’re chillin’ on the beach with a cold one, watching the waves roll in—except instead of talking about swell forecasts, we’re diving into a bill that’s trying to shine a light on how health insurance companies play the prior authorization game. This is HR 9396, the *Prior Authorization Accountability Act*, introduced by Mr. Goldman of Texas in June 2026. Let’s paddle out and see what’s underneath the surface.

### 1. Main Purpose & Objectives The core idea here is simple but powerful: **transparency**. Right now, when your doctor says you need an MRI, a specialty drug, or even physical therapy, your insurance company often slaps on a “prior authorization” (PA) requirement—meaning they gotta review and approve it before they’ll pay. Sounds reasonable, right? But in practice, it’s often a bureaucratic nightmare: delays, denials, endless paperwork, and sometimes care gets delayed or denied altogether—even when it’s medically necessary.

This bill aims to fix that by forcing insurance companies and group health plans to **publicly display** how often they deny prior authorization requests, how long it takes them to decide, whether those denials get overturned on appeal, and even if they’re using AI or algorithms to make those calls. The goal? Shine a spotlight on patterns of denial, deter unfair or overly restrictive practices, and give patients, providers, and regulators the data they need to hold insurers accountable. It’s about turning the fog of prior auth into clear, sunny skies.

### 2. Key Provisions & Changes to Existing Law HR 9396 amends three major federal laws to make this happen: - **Public Health Service Act (PHSA)** – via a new Section 2799A-12 - **Employee Retirement Income Security Act (ERISA)** – via new Section 727 - **Internal Revenue Code (IRC)** – to ensure tax-advantaged plans (like those tied to HSAs) are covered too

Starting for plan years beginning **on or after January 1, 2027**, any group health plan or health insurer that uses prior authorization must: - Publish a **list of all services** subject to PA (like MRIs, specialty meds, home health care). - Report **approval and denial rates**, both overall and broken down by service type. - Track how many denials are **appealed**, and what percentage of those appeals are **eventually approved** (including at each level—internal review, external review, even court). - Disclose the **average and median time** it takes to make a PA decision (in hours), excluding incomplete submissions. - Reveal how often decisions are made **solely by technology**—like AI, machine learning, or clinical decision support tools—and describe what tech they’re using.

All this data has to be submitted to federal agencies (like HHS, DOL, IRS) and posted **plainly on the insurer’s public website**, so anyone can look it up—no jargon, no hoops.

### 3. Affected Parties & Stakeholders This hits a bunch of key players: - **Health Insurance Issuers** (big names like UnitedHealthcare, Anthem, Kaiser, etc.) – They’ll need to build new reporting systems, track PA data meticulously, and face public scrutiny if their denial rates look sketchy. - **Group Health Plans** (employer-sponsored coverage) – Same deal; ERISA plans aren’t off the hook. - **Patients** – Big winners here. More transparency means better insight into whether their insurer is playing fair—or just delaying care to save money. - **Providers** (doctors, hospitals) – They’ll get ammo to challenge unfair denials and advocate for patients with real data. - **Regulators** (HHS, DOL, IRS, state insurance commissioners) – Gain a powerful new tool to monitor compliance and spot bad actors. - **Exchanges (ACA Marketplaces)** – If a plan is sold via Healthcare.gov or

**Prior Authorization Accountability Act (HR 9396) – Summary & Analysis**

**1. Main Purpose & Objectives** The Prior Authorization Accountability Act seeks to increase transparency in health insurance prior authorization practices by mandating the public disclosure of claim denial rates, approval metrics, appeal outcomes, processing times, and the use of automated decision-making technologies. The bill aims to curb abusive or opaque prior authorization practices that delay or deny medically necessary care, empower patients and providers with data, and enable regulators and policymakers to identify patterns of misuse or overreliance on cost-containment algorithms.

**2. Key Provisions & Changes to Existing Law** HR 9396 amends three major federal statutes: - **Public Health Service Act (PHSA)**: Adds Section 2799A-12 requiring group health plans and insurers (including those on ACA Exchanges) to submit and publish detailed prior authorization data to HHS and on public websites. - **ERISA**: Adds Section 727 imposing identical transparency requirements on employer-sponsored group health plans. - **Internal Revenue Code**: Implicitly extends compliance obligations to tax-advantaged health plans (e.g., HSAs, HRAs) via cross-reference to ERISA/PHSA standards.

Required disclosures include: - Lists of services subject to prior authorization - Approval/denial rates (aggregate and by service) - Appeal volumes and outcomes (by level, including judicial review) - Average/median processing times (in hours) - Use and description of AI/machine learning or clinical decision-support tech in denials/approvals

Data must be reported annually starting with plan years beginning January 1, 2027, and made publicly accessible in a standardized format.

**3. Affected Parties & Stakeholders** - **Health Insurers & TPAs**: Must build reporting infrastructure; face reputational and regulatory risk if denial rates appear excessive or biased. - **Group Health Plans (Employers)**: Subject to ERISA amendments; may face pressure to renegotiate with insurers based on transparency data. - **Patients & Providers**: Gain access to actionable data on plan performance, potentially reducing administrative burden and care delays. - **HHS & State Insurance Regulators**: Gain enforcement tools and data for oversight; may use metrics to inform rate reviews or network adequacy standards. - **Health IT/AI Vendors**: Increased scrutiny on algorithms used in utilization management; may drive demand for explainable, auditable tools.

**4. Potential Impact & Implications** The bill could significantly shift incentives in utilization management. Public exposure of high denial rates—especially for high-cost services like imaging, specialty drugs, or inpatient care—may prompt plans to relax overly restrictive protocols to avoid reputational damage or regulatory scrutiny. Conversely, plans may defend denials as clinically appropriate, potentially fueling debate over what constitutes medical necessity.

The focus on AI/ML disclosure addresses growing concern over “black box” denials; requiring transparency could spur innovation in fairer, more accountable algorithms—or lead to reduced reliance on automation if legal risk increases.

While not banning prior authorization, the bill leverages sunlight as a disinfectant. If enacted, it could reduce unnecessary administrative burdens, improve timely access to care, and provide Congress with empirical data for future reform. However, compliance costs may be passed to consumers via premiums, and small plans may struggle with reporting burdens without federal technical assistance.

Ultimately, HR 9396 reflects growing bipartisan frustration with prior authorization abuse—and signals a move toward accountability through transparency rather than outright prohibition.