In the wake of the killing of Brian Thompson, the CEO of UnitedHealthcare, and the outpouring of frustration about insurance coverage, prior authorizations have emerged as a particular roadblock in healthcare.

Prior authorization requires medical providers to get an insurer’s approval before patients receive healthcare or medications.

“As a physician, prior authorization is the number one frustrating thing of practicing outpatient medicine right now, far and away,” said Dr Gabriel Bosslet, a pulmonologist and professor at Indiana University School of Medicine.

“I spend more time trying to figure out how I need to get this medication approved than I do seeing the patient and making a diagnosis and writing the prescription.”

Originally intended to control the costs of certain medications and treatments, the frequency of prior authorization requirements has risen in recent years and they now plague common and inexpensive care.

“This didn’t really happen five or seven years ago,” Bosslet said.

Miranda Yaver, assistant professor of health policy and management at the University of Pittsburgh, noted that “prior authorization is something that really proliferated with the growth of managed care in the United States”.

One study found reforms such as setting maximum time periods for insurers to respond and standardizing requests would help give patients needed care.

Several states and Washington DC have passed laws to reform prior authorization practices.

A federal bill that would expedite authorizations like these for Medicare Advantage plans was also reintroduced this year in Congress. In January, the Centers for Medicare and Medicaid Services finalized a new rule to streamline prior authorizations as a way to cut costs.

Nearly one-quarter (24%) of doctors say that prior authorization has “led to a serious adverse event for a patient in their care”, according to a survey from the American Medical Association (AMA).

Yaver interviewed a patient with severe immunodeficiency who was denied medication because her multiple infections were bad, but not yet life-threatening – “a mind-boggling assessment”, Yaver said.

The incoming Trump administration has signaled greater support for programs like Medicare Advantage, in which 99% of enrollees are required to have prior authorization. That could mean more administrative burdens, more denials and hampered access to care, Yaver said.

Medical practices report an average of 43 prior authorization requests per doctor each week, the AMA survey said. That’s why more than a third (35%) employ staff whose only job is to manage prior authorizations.

Even so, some requests still make it to physicians.

Bosslet usually works with patients in the hospital, but once a week he sees them in a clinic. Every other clinic day, he estimates, he has to appeal denials by insurers of prior authorizations, even after the staff submits all of the necessary paperwork.

Recently, that meant battling with an insurer to prescribe a common asthma treatment to a patient who has relied on the medication for more than a year.

He called the number listed on the paperwork and eventually reached a person on the other end of the line who directed Bosslet to download a form buried in the insurer’s website.

Days after submitting it, he received notice that he hadn’t completed the form quickly enough. To appeal a second time, he had to call a new number, which eventually directed him to a fax number where he could send the new appeal – but without giving him information on what form to use or what information was needed about the prescription.

Part of the confusion is that “prior authorization” means something different to each insurer and each plan, with different forms, questions and process for submitting.

“It’s like you have to learn a completely new language every time you get an appeal denied,” Bosslet said.

And all of this work needs to happen in addition to providers’ time with patients.

“I’m trying to handle that in my clinic when I have patients scheduled,” Bosslet said, adding that the whole process seems designed to get providers to give up.

“The system is functioning exactly as designed, to be confusing and put people in positions where they have to spend more money,” he said.

Bosslet continued: “People are frustrated that health insurance companies make billions of dollars.

“There’s a lot of frustration about the fact that these institutions are taking massive amounts of money out of the healthcare system and doing it at the expense of sick people.”

The insurer, Wellcare, did not respond to press inquiries. When contacted the first time, an automatic message from Wellcare said to expect a response within 24 hours; when contacted three days later, the message instructed journalists to email a different media account.

Bosslet sent the insurer a new form with information it requested – information that was on the original prescription. That still didn’t work.

“I’m livid,” Bosslet said.

The first issue with the asthma prescription arose on 4 December. As of press time, the medication still hadn’t been approved. It costs $31.