‘Ghost network’ of American healthcare providers amounts to fraud

Many people have probably had the experience of needing a psychologist, therapist, or addiction specialist and struggling to find one covered by their insurance.

But despite the seemingly extensive directory of some insurance plans, call after call ends in frustration. Maybe the doctor isn’t accepting new patients, the phone numbers are inaccurate or disconnected, or the doctor canceled your insurance a long time ago. Maybe the doctor doesn’t even exist.

This phenomenon has a name: the ‘ghost network’.

And a new one class action lawsuit claims that Anthem Blue Cross Blue Shield of New York maintains a ghost network so narrow that patient advocates called it “simply staggering.”

“A lot of people have been confronted with these kinds of issues and they don’t talk about it because mental health is not something people want to talk about,” said Jacob Gardener, an attorney at Walden Macht Haran & Williams LLP, the law firm that brought the case .

Lawyers for the plaintiffs, who were not named to protect their privacy, said they were replicating the experience of a patient trying to find a mental health provider in the insurance company’s directory. They called the first 100 providers listed in Anthem’s directory, but were only able to make appointments with seven. Some stopped accepting insurance, others were listed with incorrect specialties or wrong phone numbers, or did not accept patients within the next six months.

The alleged “ghost network” in the new lawsuit took place in a plan for people in the Federal Employee Health Benefits plan. Lawyers said the insurer engaged in “a misleading advertising campaign designed to lure people into their plans.”

The lawsuit comes at a time when experts say the US is in the midst of a mental health crisis. A recent report from the Pew Charities states that the crisis is actually three overlapping crises: a youth mental health crisis, with reports of rising depression and suicides, a substance use crisis often described in overdose deaths, and a crisis of serious mental illness cause homelessness and incarceration.

The lawsuit’s findings align with studies conducted by academics, the U.S. Senate Finance Committee and the U.S Office of Government Accountabilityall of which found that the majority of mental health providers in the insurance networks surveyed were unavailable for appointments.

“These are deceptive business practices and these insurance companies must be held accountable in court,” said Democratic Senator Tina Smith of Minnesota. Smith submitted a bill to fine insurance companies for, among other things, incorrect telephone directories.

Smith said insurers “are not following the letter and spirit of the mental health parity law”, which requires companies to cover mental health to the same extent as physical health. In addition, the provisions of the No surprises law Require insurers to review their provider networks every 90 days, and to pay bills incurred as a result of incorrect listings as if they were in-network.

“It’s a little sad to think that we would have to pass a law that says, ‘You really have to do this and we will punish you if you don’t,’ but I think this is another important step that we need to to take. ,” said Smith.

The U.S. Senate Finance Committee investigated ghost networks in Medicare Advantage plans, private insurance available to Medicare beneficiaries, and a public health insurance program for older and disabled Americans. The plans have been widely investigated for unscrupulous business practices. More than 80% of providers were “ghosts” – unreachable, out of network or unavailable for appointments.

In a 2020 study, academics in Louisiana studied the problem in Medicaid, the public insurance program for low-income and disabled people. Only 25% of the more than 2,600 healthcare providers accepted new patients. A 2017 study focused on psychiatrists treating children and adolescents in five US cities – they were only able to make appointments with 17% of the providers listed. A 2015 study in three U.S. cities found that 22% of adult psychiatrists’ phone numbers were incorrect and 21% were not accepting new patients.

“We are in a mental health crisis and health care plans need to expand,” said Sue Abderholden, executive director of NAMI Minnesota, or the National Alliance on Mental Illness. She said the problem of ghost networks is partly a problem of workforce dynamics.

A recent one ProPublica investigation found that for many mental health providers, it’s simply not worth it to be part of insurance networks. Low wages and insurance policies, such as clawback provisions that allow insurers to deposit directly into bank accounts, make it unworkable to stay in network.

“As a result, there are fewer practitioners who are insured, which obviously impacts patient access,” said London Breedlove, a licensed psychologist and director of professional affairs at the Washington State Psychological Association.

“But as a consumer you don’t necessarily know that. If you have a commercial health insurance plan and you go to your insurance website and say, ‘I want a health care provider’ and enter your zip code, it looks like there are a lot of people taking patients.”

More than half of Americans live in an area with a shortage of mental health providers – and the problem is expected to become even more acute by 2036.

“We are seeing a significantly higher percentage of patients in our state who need to go out of network to access essential mental health services,” Breedlove said.

For those who do accept insurance, mental health providers are generally paid only $0.76 for every $1 paid to primary care providers, covering physical health.

Breedlove is advocating for a bill in Washington state that would tie mental health reimbursements to inflation. With this adjustment to the cost of living, she hopes that insurance will become more attractive to her colleagues.

“If you don’t have enough people in your network to have an adequate network, you have to pay them more to recruit them,” says Abderholden. “When that starts to happen, we’ll see better access because people won’t be falling out of the field. We will make sure people earn enough to pay their student loans.”