CDC Admits Its Opioid Prescribing Guidelines Have Hurt Chronic Pain Patients

Posted on May 7, 2024 by Pharmaciststeve

The CDC guidelines were not created by the CDC but by a dozen or so of “so-called experts” If these people on that committee were “experts” should they not have known that what they created -2016 CDC guidelines -potential to do harm? Could they be financially liable for all the harm that was caused directly & indirectly? I don’t know if the CDC paid those people on the committee – or they just volunteered to have the chance to put “their stamp/beliefs” on the chronic pain community. If they were paid… many were DOCTORS… The CSA states that no one can prescribe a controlled med without doing an in-person exam… While probably none on the committee directly treated pts, they used the perceived creditability of the CDC to convince the DEA, and VA to implement the guidelines as a standard of care and best practices and > 50% of our state legislators to codify these guidelines into law.

CDC Admits Its Opioid Prescribing Guidelines Have Hurt Chronic Pain Patients

https://themighty.com/topic/chronic-pain/cdc-opioid-guidelines-hurt-chronic-pain-patients/

On Wednesday, the Centers for Disease Control and Prevention (CDC) issued a clarification regarding the federal guidelines for opioid prescriptions that were put into place in 2016. The paper, published by CDC researchers in the New England Journal of Medicine, stated that many of the guidelines have been misapplied, causing serious harm to chronic pain patients.

The original prescribing guidelines were intended for primary care physicians treating adults with chronic pain (pain that lasts more than three months) outside of active cancer treatment, palliative care and end-of-life care.

“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function, and reduce the number of persons who develop opioid use disorder, overdose, or experience other adverse events related to these drugs,” the CDC wrote.

While many medical and health policy communities embraced the guidelines, CDC researchers said some clinicians and policy-makers have misinterpreted them, taking the recommendations too far.

The paper published this week reported that some physicians have encouraged “hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician’s practice.” The guidelines have also been mistakenly applied to patients with pain associated with cancer, surgical procedures or sickle cell crises – patients who were not included in the original recommendations.

CDC researchers offered several examples of the ways in which their guidelines had been wrongly implemented. They wrote:

For example, the guideline states that ‘Clinicians should…avoid increasing dosage to ≥90 MME [morphine milligram equivalents]/day or carefully justify a decision to titrate dosage to ≥90 MME/day.’ This statement does not address or suggest discontinuation of opioids already prescribed at higher dosages, yet it has been used to justify abruptly stopping opioid prescriptions or coverage.

This misapplication can have major consequences for people with chronic pain. Researchers explained that forcing patients to abruptly taper their dosages can lead to opioid withdrawal, increased pain or other adverse psychological and physical outcomes. Too little is known about the benefits and harms of reducing high dosages of opioids in physically dependent patients for researchers to recommend this strategy to physicians.

Mighty contributor Chris Jolley was one of many people with chronic pain adversely affected by these misimplemented guidelines. In his essay “When a Doctor Forced Me to Taper Off Pain Medication,” he wrote:

I was with my pain doctor on the same medication for 20 years when the medications that control my chronic pain were stopped without my consent. …

I live in unbearable pain 24/7. I’m one of the many people in pain whose doctors have abandoned us and ignored our pleas for help. Many pharmacists profile us based on their perception of our appearance. Some will not even fill prescriptions from cancer patients.

I have disability benefits awarded by my government for intractable pain, yet I suffer discrimination and cannot get treatment for that pain. Until our government admits the epidemic is about street drugs like fentanyl and heroin and stops persecuting people in pain, there will be more and more deaths by overdose from street drugs and more pain patients suffering.

Since the CDC’s guidelines were published in 2016, the number of opioid prescriptions has decreased. In May 2018, SERMO, a social network for physicians, conducted a study of 3,000 physicians and found that seven out of 10 said they cut back on prescribing opioids or stopped prescribing them entirely in the last two years. When SERMO conducted the same study in 2016, six out of 10 doctors said they were cutting back.

Among doctors who had cut back, 22 percent said it was because there were “too many hassles and risks involved,” while 34 percent said chronic pain patients have been hurt by the reduction in opioid prescriptions.

Research has shown that limiting opioid prescriptions does not have an effect on the rates of death and addiction in the U.S. According to reports from the CDC, opioid deaths in the U.S. are rising, with a 9.6 percent increase from 2016 to 2017. But this increase is due to fentanyl, not prescription opioids.

Researchers said the CDC is examining the impact its 2016 guidelines have had on pain patients and will update them when new evidence is available. “Until then, we encourage implementation of recommendations consistent with the guideline’s intent,” they said.

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Doc Blows Whistle on Cigna

Posted on May 5, 2024 by Pharmaciststeve

Doc Blows Whistle on Cigna

https://www.medpagetoday.com/special-reports/features/109910

Cigna increased efforts to speed up claims denials using new software and performance measures that pressured medical directors to close cases without a full review, according to a ProPublica investigationopens in a new tab or window.

The insurance company reportedly pressured medical directors who fell behind in reviewing cases, and even threatened to fire them if they failed to work faster, according to Debby Day, MD, a medical director who worked at Cigna for more than 15 years.

Often, the company encouraged doctors to “cut and paste the denial language that the nurse had prepared and quickly move on to the next case,” according to Day. This practice became so common that Cigna employees took to calling the approach “click and close.”

The company reportedly measured the pace and total number of cases that each medical director closed, which involved a productivity dashboard that tracked performance. Day told ProPublica the only way to keep up with expectations was to “deny, deny, deny.”

But Day told ProPublica that she believed her work was too important to speed through. Medical directors at Cigna were given the responsibility to approve or reject payment requests for critical care such as complex surgeries. And while the insurance company was pressuring doctors to work faster, Day said the work of the nurses “was getting sloppy,” which made reviewing claims harder and more meticulous.

Cigna told ProPublica that medical directors are not permitted to “rubber stamp” nurse denials and the company expects case reviewers to “perform thorough, objective, independent, and accurate reviews in accordance with our coverage policies.”

Longevity Scientist Faces Blowback

A Harvard geneticist who became the face of the longevity movement has drawn increasingly harsh criticism for claiming his products can reverse aging, according to the Wall Street Journalopens in a new tab or window.

Last year, David Sinclair, PhD, faced backlash for posting on social media that a gene therapy invented in his lab and developed by his company, Life Biosciences, had successfully reversed aging in monkeys. He also claimed the therapy had restored vision in the monkeys.

Earlier this year, Sinclair reportedly said another company he co-founded had developed a supplement that had reversed aging in dogs, according to WSJ.

However, other longevity science experts called this an empty promise. There isn’t an accepted standard for measuring aging, let alone a definition of what it means to “reverse” it, they said. The criticism was paired with the resignations of scientists from the Academy for Health and Lifespan Research, a group that Sinclair co-founded and led. Of the roughly 60 members who resigned, one posted on social media that Sinclair was a “snake oil salesman.”

The Academy’s remaining board members called for Sinclair to step down as president, which he eventually agreed to do.

Sinclair made a name for himself by promoting scientific claims about his work that garnered interest from top-tier scientific journals as well as praise in the news and on social media. But he has increasingly drawn criticism for hyping his own research or promoting unproven products, especially when he stood to benefit financially.

“The data is not good, you’re calling it the wrong thing, and then you’re selling it,” Nir Barzilai, MD, the new president of the Academy and the director of the Institute for Aging Research at Albert Einstein College of Medicine in New York, told WSJ. “The selling is a step too far.”

Fertility Clinic Accidents

The growing fertility industry has been plagued by an opaque system that frequently hides major errors and accidents, according to a Washington Post investigationopens in a new tab or window.

Many fertility centers are not required to report errors or accidents, including lost or damaged embryos, to any government or professional oversight organization, the report found. The industry relies largely on self-policing, which means patients are rarely informed immediately after something has gone wrong.

The Post highlighted two accidents that resulted in the loss of thousands of eggs and embryos belonging to hundreds of individuals and couples. One accident in San Francisco involved the implosion of a cryopreservation tank that contained 4,000 eggs and embryos. Another incident in Cleveland resulted in the loss of 4,000 eggs and embryos after a similar storage tank failed.

Both incidents occurred over the same weekend in March 2018, the Post reported.

Industry representatives insisted that error rates are low, and experts told the Post that fertility practitioners are regulated similar to other medical disciplines. Patients are also able to use the courts to address mismanagement of genetic material, experts said.

In fact, the Alabama Supreme Court ruling that frozen embryos are children came during a dispute over the mishandling of human embryos. But experts claim that most lawsuits end in settlements with nondisclosure provisions reinforcing the secrecy around the fertility industry.

Still, Adam Wolf, a prominent attorney for fertility plaintiffs, told the Post that the “vast, vast supermajority of mistakes in fertility clinics, the public doesn’t even know about.”

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In Re: National Prescription Opiate Litigation transcript

Posted on May 3, 2024 by Pharmaciststeve

In Re: National Prescription Opiate Litigation

(Exhibit B – 3.28.24 hearing transcript)Related document(s)

https://www.docketbird.com/court-documents/In-re-National-Prescription-Opiate-Litigation/-Exhibit-B-3-28-24-hearing-transcript-Related-document-s/ohnd-1:2017-md-02804-05402-002

It is only 160+ pages

 

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R.I.P. Robert Charles Foster: suicide by cop

Posted on May 3, 2024 by Pharmaciststeve

R.I.P.
Robert Charles Foster

Robert Charles Foster, a male from Oregon died by suicide. ‘(or as he phrased it, “suicide by cop”). Foster told the police during a previous suicide attempt, “I had been in chronic, constant pain, and was for whatever reason, not able to get the medication he needed for it.” He was 65 years old. He came out of a building with a gun, and would not drop it, on the command from the police. They shot and killed him – this was his intention.’

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Pain Management Physician Convicted of Unlawfully Distributing Opioids

Posted on May 3, 2024 by Pharmaciststeve

Notice in this DOJ press release, that they stated that individuals traveled hundreds of miles to obtain prescriptions for opioids and other controlled substances – one of those DEA RED FLAGS. Generally, RED FLAGS are policies that the DEA adopts from observing what many/addicts/diverters do.  Let’s look at the simple math.  Over a ~ 6-year period of time, Romano prescribed 137,000 doses of three controlled substances to 9 pts.  137,000/6 yrs = 22,833 doses given to 9 pts = 2,537 doses to each pt which equals ~ a total of  7 doses of those three meds daily – on average. That could break down to, 2 opioids a day, 4 muscle relaxants a day, and a benzodiazepine at bedtime for sleep. Not knowing the mgs of each med, this could be appropriate for many pts dealing with intractable chronic pain!

I noticed that there was no mention of any of his pts ODing/dying, and the pts were addicted to these medications. Do they know the difference between addiction and dependency when these categories of meds are appropriately prescribed long-term?  It took 3 attorneys from the Criminal Division’s Fraud Section, “gin-up” 24 counts against Romano. Of course, each count could be worth 20 yrs in prison for Romano. Given Romano’s age (73 y/o), one count could end up being a LIFE SENTENCE, let alone the 480 yrs Romano is potentially looking at.

Pain Management Physician Convicted of Unlawfully Distributing Opioids

https://www.justice.gov/opa/pr/pain-management-physician-convicted-unlawfully-distributing-opioids-0

A federal jury in the Southern District of Ohio convicted an Ohio physician today for unlawfully distributing opioids from his clinic.

According to court documents and evidence presented at trial, Thomas Romano, 73, of Wheeling, West Virginia, owned and operated a self-named pain management clinic in Martin’s Ferry to which individuals traveled hundreds of miles to obtain prescriptions for opioids and other controlled substances. Romano charged $750 for an initial visit and $120 for subsequent monthly visits. The prescriptions Romano issued for opioids and other controlled substances greatly exceeded recommended dosages and were in dangerous, life-threatening combinations that fueled the addiction of the individuals to whom he prescribed. Between October 2014 and September 2019, Romano prescribed over 137,000 pills, including opioids, benzodiazepines, and muscle relaxants, to nine individuals.

The jury convicted Romano of 24 counts of unlawful distribution of a controlled substance, outside the usual course of professional practice, and not for a legitimate medical purpose to nine individuals. He faces a maximum penalty of 20 years in prison for each charge. A sentencing date has not yet been set. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

Acting Assistant Attorney General Nicole M. Argentieri of the Justice Department’s Criminal Division, U.S. Attorney Kenneth L. Parker for the Southern District of Ohio, Special Agent in Charge Orville O. Greene of the Drug Enforcement Administration (DEA) Detroit Division, Special Agent in Charge J. William Rivers of the FBI Cincinnati Field Office, and Special Agent in Charge Mario M. Pinto of the Department of Health and Human Service Office of the Inspector General (HHS-OIG) made the announcement.The DEA, FBI, and HHS-OIG, as well as the Ohio Bureau of Worker’s Compensation and Ohio Board of Pharmacy, investigated this case.

Assistant Chief Alexis Gregorian and Trial Attorneys Devon Helfmeyer and Danielle Sakowski of the Criminal Division’s Fraud Section are prosecuting the case.

The Fraud Section leads the Appalachian Regional Prescription Opioid (ARPO) Strike Force. Since its inception in late 2018, ARPO has partnered with federal and state law enforcement agencies and U.S. Attorneys’ Offices throughout Alabama, Kentucky, Ohio, Virginia, Tennessee, and West Virginia to prosecute medical professionals and others involved in the illegal prescription and distribution of opioids. Over the past four years, ARPO has charged over 115 defendants, collectively responsible for issuing prescriptions for over 115 million controlled substance pills. To date, more than 60 ARPO defendants have been convicted. More information can be found at www.justice.gov/criminal-fraud/health-care-fraud-unit.

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Equal Protection Clause- another law on the books to protect chronic pain pts

Posted on May 2, 2024 by Pharmaciststeve

Equal Protection Clause

https://en.wikipedia.org/wiki/Equal_Protection_Clause

The Equal Protection Clause is part of the first section of the Fourteenth Amendment to the United States Constitution. The clause, which took effect in 1868, provides “nor shall any State … deny to any person within its jurisdiction the equal protection of the laws.” It mandates that individuals in similar situations be treated equally by the law.[1][2][3]

A primary motivation for this clause was to validate the equality provisions contained in the Civil Rights Act of 1866, which guaranteed that all citizens would have the guaranteed right to equal protection by law. As a whole, the Fourteenth Amendment marked a large shift in American constitutionalism, by applying substantially more constitutional restrictions against the states than had applied before the Civil War.

The meaning of the Equal Protection Clause has been the subject of much debate, and inspired the well-known phrase “Equal Justice Under Law“. This clause was the basis for Brown v. Board of Education (1954), the Supreme Court decision that helped to dismantle racial segregation. The clause has also been the basis for Obergefell v. Hodges which legalized same-sex marriages, along with many other decisions rejecting discrimination against, and bigotry towards, people belonging to various groups.

While the Equal Protection Clause itself applies only to state and local governments, the Supreme Court held in Bolling v. Sharpe (1954) that the Due Process Clause of the Fifth Amendment nonetheless requires equal protection under the laws of the federal government via reverse incorporation.

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Warren Blasts United Health CEO for Monopolistic Practices that Harm Patients

Posted on May 2, 2024 by Pharmaciststeve

United Health Care for ALL

 

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CVS Health stock price drops nearly 20% in two days

Posted on May 2, 2024 by Pharmaciststeve


This could be the proverbial “canary in the coal mine”. Several major healthcare providers did not renew their contracts with a number of Medicare-C (Advantage) programs for 2025.

All insurance providers of Medicare-C and Medicare-D are FOR PROFIT.  CVS stated in this article that it experienced increased Medicare utilization. If you have Medicare-C or Medicare-D insurance, you might want to carefully read the new policy you will be signing up for during open enrollment – October 15th to December 7 2024 for insurance coverage for 2025.

CVS Health drops as medical cost trends prompt guidance cut

https://www.msn.com/en-us/money/markets/cvs-health-drops-as-medical-cost-trends-prompt-guidance-cut/ar-AA1nYy2Q

CVS Health (NYSE:CVS) shares traded sharply lower in the premarket on Wednesday after the pharmacy chain operator reported lower-than-expected Q1 2024 financials and slashed its full-year outlook below consensus, citing medical cost trends.

While the Woonsocket, Rhode Island-based healthcare giant’s revenue for the quarter rose ~4% YoY to $88.4B, exceeding expectations, its Health Services segment, which includes its PBM unit Caremark, underperformed.

CVS’ Health Services segment added $40.3B to the topline, indicating a ~10% YoY drop due to multiple reasons, including the loss of a major client during the period.

However, the company’s Health Care Benefits segment, which houses its insurance arm Aetna, and CVS’ Pharmacy & Consumer Wellness segment outperformed, bringing in $33.2B and $28.7B in revenue with ~25% YoY and ~3% YoY growth, respectively.

Meanwhile, CVS’ bottom line fell during the quarter, with adjusted earnings per share reaching $1.31 with a ~41% YoY drop as the company’s adjusted operating income slumped ~32% YoY to $3.0B amid declines in the Health Care Benefits and Health Services segments.

In the Health Care Benefits unit, adjusted operating income decreased by ~60% YoY to $732M as the medical benefits ratio, which calculates the share of premiums spent on medical benefits, reached ~90% compared to ~85% a year ago.

CVS attributed the MBR spike to several factors, including increased Medicare utilization and the unfavorable impact of the company’s 2024 Medicare Advantage star ratings.

“We are confident we have a pathway to address our near-term Medicare Advantage challenges,” CEO Karen Lynch remarked ahead of the conference call at 8:00 a.m. EST. “We remain committed to our strategy and believe that we have the right assets in place to deliver value to our customers, members, patients, and shareholders.”

However, expecting the pressure on medical utilization to continue to impact its Health Care Benefits segment throughout the year, the company lowered its 2024 adj. EPS outlook to at least $7.00 from at least $8.30, compared to $8.27 in the consensus.

With CVS citing pressure on medical utilization, shares of other health insurers will be in focus. In January, Humana (HUM) led a selloff among health insurers such as UnitedHealth (UNH), Alignment Healthcare (ALHC), Elevance Health (ELV), and Centene (CNC) after the managed care provider set its 2024 outlook below consensus, expecting a spike in medical costs to continue this year.

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US poised to ease restrictions on marijuana in historic shift, but it’ll remain controlled substance

Posted on May 1, 2024 by Pharmaciststeve

This poses an interesting conundrum. Being de-classified to a C-3, may encourage some pharmas to do some clinical research on some of the components of MJ. MJ being classified as a C-1 prohibited research. I have read that there have been at least 100 different components isolated from MJ and there may be that many or more that have yet to be isolated.

If it is made an Rx-only item, I doubt if any insurance will pay for it, but states will lose a lot of sales tax. Since all Rxs are sales tax-free.

US poised to ease restrictions on marijuana in historic shift, but it’ll remain controlled substance

https://www.msn.com/en-us/news/opinion/us-drug-control-agency-will-move-to-reclassify-marijuana-in-a-historic-shift-ap-sources-say/ar-AA1nWuQg

WASHINGTON (AP) — The U.S. Drug Enforcement Administration will move to reclassify marijuana as a less dangerous drug, The Associated Press has learned, a historic shift to generations of American drug policy that could have wide ripple effects across the country.

The proposal, which still must be reviewed by the White House Office of Management and Budget, would recognize the medical uses of cannabis and acknowledge it has less potential for abuse than some of the nation’s most dangerous drugs. However, it would not legalize marijuana outright for recreational use.

The agency’s move, confirmed to the AP on Tuesday by five people familiar with the matter who spoke on the condition of anonymity to discuss the sensitive regulatory review, clears the last significant regulatory hurdle before the agency’s biggest policy change in more than 50 years can take effect.

Once OMB signs off, the DEA will take public comment on the plan to move marijuana from its current classification as a Schedule I drug, alongside heroin and LSD. It moves pot to Schedule III, alongside ketamine and some anabolic steroids, following a recommendation from the federal Health and Human Services Department. After the public comment period and a review by an administrative judge, the agency would eventually publish the final rule.

The proposal will be formally signed by Attorney General Merrick Garland, whose agency has ultimate oversight of the DEA, according to another person familiar with the process who spoke on the condition of anonymity to discuss internal deliberations. Garland’s signature throws the full weight of the Justice Department behind the move and appears to signal its importance to the Biden administration.

It comes after President Joe Biden called for a review of federal marijuana law in October 2022 and moved to pardon thousands of Americans convicted federally of simple possession of the drug. He has also called on governors and local leaders to take similar steps to erase marijuana convictions.

“Criminal records for marijuana use and possession have imposed needless barriers to employment, housing, and educational opportunities,” Biden said in December. “Too many lives have been upended because of our failed approach to marijuana. It’s time that we right these wrongs.”

The election year announcement could help Biden, a Democrat, boost flagging support, particularly among younger voters.

Biden and a growing number of lawmakers from both major political parties have been pushing for the DEA decision as marijuana has become increasingly decriminalized and accepted, particularly by younger people. A Gallup poll last fall found 70% of adults support legalization, the highest level yet recorded by the polling firm and more than double the roughly 30% who backed it in 2000.

The DEA didn’t respond to repeated requests for comment.

Schedule III drugs are still controlled substances and subject to rules and regulations, and people who traffic in them without permission could still face federal criminal prosecution.

Some critics argue the DEA shouldn’t change course on marijuana, saying rescheduling isn’t necessary and could lead to harmful side effects.

Jack Riley, a former deputy administrator of the DEA, said he had concerns about the proposed change because he thinks marijuana remains a possible “gateway drug,” one that may lead to the use of other drugs.

“But in terms of us getting clear to use our resources to combat other major drugs, that’s a positive,” Riley said, noting that fentanyl alone accounts for more than 100,000 deaths in the U.S. a year.

On the other end of the spectrum, others argue marijuana should be treated the way alcohol is.

Last week, 21 Democrats led by Senate Majority Leader Sen. Chuck Schumer of New York sent a letter to DEA Administrator Anne Milgram and Attorney General Merrick Garland arguing marijuana should be dropped from the controlled-substances list and instead regulated like alcohol.

“It is time for the DEA to act,” the lawmakers wrote. “Right now, the Administration has the opportunity to resolve more than 50 years of failed, racially discriminatory marijuana policy.”

Federal drug policy has lagged behind many states in recent years, with 38 having already legalized medical marijuana and 24 legalizing its recreational use.

That’s helped fuel fast growth in the marijuana industry, with an estimated worth of nearly $30 billion. Easing federal regulations could reduce the tax burden that can be 70% or more for businesses, according to industry groups. It could also make it easier to research marijuana, since it’s very difficult to conduct authorized clinical studies on Schedule I substances.

The immediate effect of rescheduling on the nation’s criminal justice system would likely be more muted, since federal prosecutions for simple possession have been fairly rare in recent years.

But loosening restrictions could carry a host of unintended consequences in the drug war and beyond.

Critics point out that as a Schedule III drug, marijuana would remain regulated by the DEA. That means the roughly 15,000 cannabis dispensaries in the U.S. would have to register with the DEA like regular pharmacies and fulfill strict reporting requirements, something that they are loath to do and that the DEA is ill equipped to handle.

Then there’s the United States’ international treaty obligations, chief among them the 1961 Single Convention on Narcotic Drugs, which requires the criminalization of cannabis. In 2016, during the Obama administration, the DEA cited the U.S.’ international obligations and the findings of a federal court of appeals in Washington in denying a similar request to reschedule marijuana.

 

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ProPublica Creates a Tool to Hold Payers Accountable

Posted on April 29, 2024 by Pharmaciststeve

ProPublica Creates a Tool to Hold Payers Accountable

https://www.daily-remedy.com/propublica-creates-a-tool-to-hold-payers-accountable/

Series: Uncovered: How the Insurance Industry Denies Coverage to Patients

Health insurers reject millions of claims for treatment every year in America. Corporate insiders, recordings and internal emails expose the system and its harm.

Just outside public view, the American health insurance industry’s algorithms, employees and executives process tens of millions of claims for people seeking medical care.

Sometimes, as ProPublica has reported, insurers base decisions on what’s good for the company’s bottom line rather than what’s good for the patient’s health. Sometimes, insurers make mistakes. In one case we learned about, a company denied a child’s treatment because it based its judgment on adult guidelines instead of pediatric ones. In another, an internal reviewer misread what type of surgery the patient sought and denied coverage based on that error.

At first, these patients had no idea why they were denied treatment. But in each instance, insurance employees left a paper trail — in notes, emails or recordings of phone calls — explaining what happened. Patients and advocates used what they found in those records to craft appeals and ultimately receive the care they needed.

Federal law and regulations require insurers to hand over exactly this sort of information in response to a written request. And they have to do it fast: Most people who get insurance through an employer should get the records, called claim files, within 30 days.

There’s just one catch: Some insurers aren’t turning files over like they’re supposed to. We followed ProPublica readers through the process with five different insurers. Several companies only shared documents with patients after we reached out.

Our team discovered how useful claim files can be after a patient shared internal notes and calculations that a health insurer had made about his case. But few health insurers advertise this service or offer clear instructions for getting these records. To help fill that gap, we published a guide explaining how to submit a claim file request. We also shared resources with health care providers and patient advocates nationwide, including request letter templates.

More than 120 people have told us that they have since requested or intend to request their claim files. Though a handful say they received information that helped them understand why their health insurer denied coverage, many more have been running into challenges. They’ve told us about insurers blowing past deadlines, wrongly requiring subpoenas and — in several cases — misinterpreting their request entirely.

We shared a summary of these examples with Tim Hauser, a deputy assistant secretary with the Department of Labor. His office oversees claim file laws that cover more than 131 million people. He said insurers who fail to provide records are breaking the law. “The claimant really needs to be able to see what the relevant evidence is so that they can respond to it,” he said.

We brought our findings to five insurance companies. We presented them with details about the requests patients had made and how the company had responded, and we asked for an explanation of what happened in each case.

All of the insurers acknowledged that the patients were entitled to the material they’d asked for. Four began sending the files after our inquiry. Two, spokespeople told us, are updating policies to handle future requests. Anthem Blue Cross Blue Shield spokesperson Michael Bowman said the company needed to better train staff on the rules “to close any gaps to prevent this from occurring in the future.” Cigna spokesperson Justine Sessions admitted that patients do not need a subpoena to access their records, contrary to what the insurer had told a member. She said the company would update its “policies and communications to reflect that for future requests. We regret that we did not make these updates sooner and apologize for any frustration or confusion this has caused our customers.”

By crowdsourcing people’s experiences, we identified some patterns in health insurers’ behavior. Here are some of the most common issues people encountered — and what to watch out for if you submit your own request:

Insurers Asking for Unnecessary Subpoenas or Court Orders

Cigna and Anthem told members that they would need to obtain a court order or subpoena to access their claim file records.

“This is completely unheard of,” said Wells Wilkinson, a senior attorney with the nonprofit legal group Public Health Advocates who regularly files these requests. “It also sounds completely illegal. The consumer has the right to any information used by the health plan in the context of the denial.”

On July 12, Lisa Kays, a Maryland resident, asked Cigna for phone call records related to its decision to deny coverage for her 4-year-old son’s speech therapy. “We couldn’t afford to just give up,” Kays said.

In September, Cigna sent her a letter saying she would need to submit a subpoena to get any transcripts or recordings.

After ProPublica inquired, the company sent Kays partial transcripts of the calls. It also reimbursed her for some of the previously denied coverage. She is still waiting for the recordings.

We asked Anthem about a similar case. On July 19, a call center agent told Pamela Tsigdinos she would need a subpoena to receive her claim file records. Tsigdinos had submitted the request 50 days earlier.

Bowman, the Anthem spokesperson, told us the response was an error and apologized. The company compiled the claim file and sent it to Tsigdinos.

Insurers Confusing Claim File Requests With Appeals

At least five people told ProPublica that, after submitting a request for a claim file, their health insurer mistook the request for an appeal.

We brought three cases to UnitedHealthcare. S.J. Farris requested her claim file from the company on May 10. Five days later, she received a response stating that her request for an appeal had been received. Farris sent a clarifying letter but was met with a call from an appeals agent based in Ireland. “I asked her to send the claim files,” Farris said. “She had no idea what I was talking about.”

After ProPublica sent the company questions, Farris received a call from UnitedHealth in October. They told her that the insurer was working on her claim file and that she should expect it soon. In a statement to ProPublica, UnitedHealth spokesperson Maria Gordon Shydlo said: “We take our responsibility to provide members access to their records seriously and have processes in place to comply with the law. We are sorry for any inconvenience.”

After Beth Tolley sent Anthem a claim file request on behalf of her granddaughter, she received a letter from the health insurer stating, “We’ve received a request from Beth Tolley for an appeal.” This left Tolley confused since, in its last communication, Anthem had said all avenues of appeal with its office had been exhausted.

In early October, Anthem sent the Tolley family a check for the amount it had initially declined to cover. Bowman told ProPublica that the company would be sending the records soon.

Insurers Blowing Past the 30-Day Deadline

For most people who get insurance through their employers, insurers are required to send claim files back within 30 days, according to federal law.

Twelve of the people whose requests ProPublica followed did not receive their records within that time frame even though they had these types of plans. Five of those had been waiting for responses from their insurers for more than 70 days before ProPublica contacted the companies with questions.

Isabella Gonzalez submitted a claim file request via certified mail on Aug. 8. When she called Aetna to get an update, a representative told her they did not see it in the system and advised her to upload it onto the insurer’s online portal, which she did. She called back a few days later. A different customer service employee told her Aetna would respond in 45 days.

Alex Kepnes, the executive director of communications for Aetna, said the company at first did not recognize what Gonzalez was asking for and therefore did not respond to it.

Kepnes declined to respond to follow-up questions about why staff failed to correctly identify the request and whether the company would be taking action to ensure this does not happen again.

Other companies that failed to follow the 30-day timeline include UnitedHealth, Anthem and Cigna.

“It’s really important that these responses be timely,” said Hauser, the Department of Labor official. “If that’s not happening, it’s really contrary to the regulation.”

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