Rhode Island is launching a three-year experiment to rethink prior authorization in healthcare. The pilot program could reshape how patients access care and how providers manage administrative burdens, while generating valuable data to inform future reforms.
What is Prior Authorization?
Prior authorization is a process in which health plans require patients to obtain approval before a health plan agrees to compensate a healthcare provider or pharmacy for a medical service or prescription. While designed as a cost-control measure, prior authorization has long been a source of frustration for patients and providers.
For example, a Kaiser Family Foundation (KFF) analysis of the Center for Medicare & Medicaid Services (CMS) data found that in 2023, Medicare Advantage insurers processed more than 50 million prior authorization requests.[1] Of these, 3.2 million were either partially or fully denied, and 11.7% of the denials were appealed.[2] Among those appealed, 81.7% were partially or fully overturned.[3]
Recent American Medical Association (AMA) survey results further illustrate the administrative burden on providers. In late 2024, a survey of 1,000 practicing physicians found that the average practice completes 39 prior authorization requests per physician, per week.[4] Physicians and staff spend 13 hours each week completing such requests.[5] Additionally, 89% of physicians report that prior authorizations somewhat or significantly increase physician burnout.[6]
Rhode Island Prior Authorization Reform Act of 2025
Amid growing concerns regarding Rhode Island’s primary care system, the General Assembly enacted new legislation addressing prior authorization. On July 2, 2025, Governor Daniel J. McKee, signed into law House Bill No. 5120 and Senate Bill No. 0168, known as the Rhode Island Prior Authorization Reform Act of 2025.[7]
The law establishes a three-year pilot program effective October 1, 2025 through October 1, 2028 that eliminates prior authorization requirements for services ordered by primary care providers in the normal course of treatment.[8] Under the Act, insurers may not impose prior authorization requirements for any “admission, item, service, treatment, or procedure ordered by an in-network primary care provider.”[9] The prohibition does not apply to prescription drugs.[10] Insurers must also submit annual reports to the Office of the Governor, the Speaker of the House of Representatives, the President of the Senate, and the Office of the Health Insurance Commissioner in compliance with the rules and regulations to be promulgated by the Office of the Health Insurance Commissioner on or before January 1, 2026.[11]
Potential Impacts of the Pilot
The Rhode Island Prior Authorization Reform Act of 2025 will likely have both benefits and challenges. By reducing prior authorization requirements for primary care services, the pilot may shorten the time patients wait for care and decrease administrative workloads for providers. This will allow the providers to focus more on direct patient care. At the same time, eliminating prior authorization as a cost-control mechanism could affect service utilization, overall healthcare spending, and insurance premiums.
Because the law is structured as a three-year pilot program with a sunset provision, it will likely generate data on whether easing prior authorization improves access to care without driving up costs. The pilot’s results will inform future decisions about whether to extend, revise, or discontinue the program.
[1] Jeannie Fuglesten Biniek, Nolan Sroczynski, Meredith Freed, & Tricia Neuman, Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023, KFF (Jan. 28, 2025), https://www.kff.org/medicare/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/.
[2] Id.
[3] Id.
[4] Id.
[5] 2024 AMA Prior Authorization Physician Survey, AMA, https://www.ama-assn.org/system/files/prior-authorization-survey.pdf.
[6] Id.
[7] See S.R. 0168, Sub B, 2025 Jan. Sess. (R.I. 2025).
[8] Id.
[9] Id.
[10] Id.
[11] Id.
About The Author
Andrew A. Halstead
Andrew is a member of the firm’s litigation group. His practice includes a wide range of civil litigation and health care-related…
