What Physicians Need to Know About the 2025 Medicare Advantage Rule Updates
With the final 2025 Medicare Advantage (MA) and Part D rule now in effect, physicians need to be aware of how these updates will impact clinical practice, patient access, and administrative workflows. These policy shifts from the Centers for Medicare & Medicaid Services (CMS) aim to increase transparency, reduce delays in care, and improve health equity, but they also introduce new compliance considerations for providers.
Here’s a breakdown of what’s changing in 2025 and what physicians should keep in mind.
Prior Authorization Reforms: A Win for Timely Care
One of the most physician-relevant updates is CMS’s move to tighten oversight around prior authorization in Medicare Advantage plans. Beginning in 2025:
- MA plans must publicly disclose prior authorization policies and clearly explain medical necessity requirements.
- Authorization decisions must be based on current clinical criteria, not proprietary insurer guidelines alone.
- Standard prior authorization requests must be reviewed within 7 calendar days, and expedited requests within 72 hours.
- Approved authorizations are valid for the full duration of treatment, ensuring continuity of care without repeated approvals.
For physicians, this means fewer delays in patient care and less back-and-forth with health plans. However, it will be critical to document medical necessity clearly and stay up to date on each payer’s published requirements.
Protecting Continuity of Care
CMS is also requiring MA plans to establish continuity of care protocols. Specifically:
- Patients must be able to maintain access to services and providers during transitions, including changes in plan year or insurance status.
- Coverage must continue for existing treatments even if a provider exits the plan network mid-course.
This is a welcome step for physicians managing chronic or complex care, reducing the administrative burden associated with reauthorizing ongoing treatments.
Changes to Utilization Management and Appeals
To curb overuse of denials and excessive administrative reviews, MA plans will be required to:
- Make utilization management criteria publicly available.
- Provide more transparent, consistent criteria for denials.
- Improve clarity and accessibility in the appeals process.
These changes aim to support clinical decision-making and reduce the time physicians and staff spend disputing denials or navigating opaque plan processes.
Advancing Health Equity
Another key element of the rule is CMS’s emphasis on improving outcomes for underserved populations. This includes:
- New requirements for Health Equity Index scoring, rewarding MA plans that improve care for enrollees with social risk factors.
- Requirements to include health equity initiatives in MA quality improvement programs, which may influence network design and care coordination priorities.
Physicians practicing in value-based care models or within health systems that contract with MA plans may see a greater focus on SDOH screening and population health tracking.
Practical Takeaways for Physicians
- Review your top MA payers’ new policies - look for updates to prior auth, appeals, and continuity of care language.
- Communicate with care coordinators and billing teams to ensure everyone is aligned on new documentation standards.
- Anticipate fewer unnecessary delays, but continue to track denials and escalate concerns when payer behavior doesn’t align with CMS expectations.
- Stay connected to referral networks - continuity of care protections may reduce disruption, but proactive communication remains key.
At PracticeMatch, we know policy changes like this directly impact your clinical efficiency and patient care. As new rules roll out, we’ll continue to provide insights and tools to help physicians stay informed, prepared, and connected to roles where they can thrive.
Clint Rosser is the CEO of PracticeMatch. He has been with PracticeMatch since 2016. He has overseen several departments within PracticeMatch including Inside Sales, Career Fairs, and the Client Services team. Clint, along with his team, has helped elevate PracticeMatch client services to move past a transactional vendor relationship to a full partnership with clients. This has allowed PracticeMatch to build stronger relationships and work with clients closer to ensure they can achieve the most ROI possible.
Prior to Joining PracticeMatch, Clint has been in Client service leadership roles for over 20 years. Clint serves as an AAPPR Board Member for Strategic Corporate Sponsors.