‘Ghost network’ of US healthcare providers amounts to fraud, lawsuit says | US healthcare

Many people have likely had the experience where they are in need of a psychologist, therapist or addiction specialist, and struggle to find one covered by their insurance.

But despite some insurance plans’ seemingly expansive directory, call after call ends in frustration. Perhaps the doctor is not accepting new patients, phone numbers are inaccurate or disconnected, or the doctor dropped your insurance ages ago. Maybe the doctor doesn’t even exist.

This phenomenon has a name – the “ghost network”.

And a new class action lawsuit alleges that Anthem Blue Cross Blue Shield of New York maintains a ghost network so narrow attorneys for patients called it “just staggering”.

“A lot of people have encountered that kind of issue and they’re not talking about it, because mental health care is not something people are willing to talk about,” said Jacob Gardener, an attorney with Walden Macht Haran & Williams LLP, the law firm that filed the suit.

Attorneys for the plaintiffs, who are not named to protect their privacy, said they replicated 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 could only make appointments with seven. Some no longer accepted the insurance, others were listed with erroneous specialties or wrong phone numbers, or were not accepting patients within the next six months.

The alleged “ghost network” in the new lawsuit occurred in a plan for people in the Federal Employee Health Benefits plan. Attorneys said the insurer engaged “in a deceptive advertising campaign intended to lure people” to their plans.

The suit comes at a time when experts say the US is in a mental health crisis. A recent report by the Pew Charitable Trusts argues the crisis is in fact three overlapping crises: a youth mental health crisis with reports of rising depression and suicide, a substance use crisis often described in overdose deaths, and a crisis of serious mental illness driving homelessness and incarceration.

The suit’s findings join studies conducted by academics, the US Senate finance committee and the US Government Accountability Office, all of which have found the majority of mental health providers in examined insurance networks were not available for appointments.

“These are deceptive business practices and these insurance companies should be held accountable in courts,” said Democratic senator Tina Smith of Minnesota. Smith introduced a bill to fine insurance companies for inaccurate directories, among other provisions.

Smith said insurers are “not following the letter and the spirit of the mental health parity law”, which requires companies to cover mental health to the same degree they cover physical health. Additionally, provisions of the No Surprises Act require insurers to review their provider networks every 90 days, and for bills acquired as a result of inaccurate listings to be paid as if they were in-network.

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

The US Senate finance committee examined ghost networks in Medicare Advantage plans, private insurance available to Medicare beneficiaries, a public health insurance program for elderly and disabled Americans. The plans have been widely scrutinized 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 more than 2,600 providers were accepting new patients. A 2017 study focused on psychiatrists who treated children and adolescents in five US cities – they were only able to make appointments with 17% of providers listed. A 2015 study across three US cities found 22% of phone numbers for adult psychiatrists were wrong and 21% were not accepting new patients.

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

A recent ProPublica investigation found that, for many mental health providers, being in insurance networks is just not worth it. Low pay and insurance policies, such as clawback provisions that allow insurers to dip directly into bank accounts, make remaining in-network unworkable.

“As a result there are fewer practitioners who are paneled with insurance, which of course affects patient access,” said London Breedlove, a licensed psychologist and director of professional affairs at the Washington State Psychological Association.

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

More than half of Americans live in a mental health provider shortage area – and the problem is expected to grow more acute by 2036.

“We see in our state there’s a significantly higher percentage of patients who have to go out-of-network to access vital mental health resources,” said Breedlove.

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

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

“If you don’t have enough people in your network to have an adequate network then you have to pay them more to recruit them,” said Abderholden. “When that starts happening, we will see better access because we won’t have people dropping out of the field. We will have people making enough to cover their student loans.”