The ‘ghost network’ of US health care providers is tantamount to fraud

Many people have likely had an experience where they needed a psychologist, psychiatrist or addiction specialist, and had a hard time finding one covered by their insurance.

But even though some insurance plans seem to be comprehensive, call after call results in confusion. Maybe the doctor isn’t accepting new patients, the phone numbers are incorrect or disconnected, or the doctor dropped your insurance years ago. Maybe the doctor isn’t here.

This phenomenon has a name – “ghost network”.

And a new class action lawsuit alleges that Anthem Blue Cross Blue Shield of New York is keeping the air network too weak for patients who called it “weird”.

“A lot of people have experienced that kind of problem and they don’t talk about it, because mental health care is not something that people are willing to talk about,” said Jacob Gardener, a spokesperson for the law of Walden Macht Haran & Williams LLP. the law firm that filed the case.

Attorneys for the plaintiffs, who are not being named to protect their privacy, said they played out the experience of a patient trying to find a mental health provider in an insurance company’s directory. They called the first 100 donors listed in Anthem’s directory but were only able to make appointments with seven. Some were no longer accepting insurance, others were listed with the wrong specialists or phone numbers, or were not accepting patients for the next six months.

The so-called “spirit network” in the new case occurred in the plan of the people of the Federal Employee Health Benefits plan. lawyers say the insurer has engaged in a “deceptive advertising campaign designed to lure people” into their plans.

The suit comes at a time when experts say the US is facing a mental health crisis. A recent report by the Pew Charitable Trusts says the crisis is actually a three-pronged crisis: a youth mental health crisis with reports of increased depression and suicide, a substance use disorder often characterized by extreme mortality, and an epidemic of serious mental illness leading to homelessness. and imprisonment.

The suit’s findings combine studies by academics, the U.S. Senate finance committee and the U.S. Government Accountability Office, all of which found the majority of mental health providers in the audited insurance networks they were not there for election.

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

Smith said insurers “are not following the letter and spirit of the Mental Health Equity Act”, which requires companies to pay for mental health at the same rate as they cover general health. the body. In addition, the provisions of the No Surprises Act require insurers to audit their network every 90 days, and for claims received as a result of incorrect lists to be paid such as if it’s the internet.

“It’s sad to think that we’re going to have to pass a law that says, ‘Of course you have to do this and we’re going to fine you if you don’t,’ but I think that’s another important step. that we should take,” said Smith.

The US Senate finance committee examined the air network in Medicare Advantage plans, private insurance available to Medicare beneficiaries, a health insurance program for the elderly and disabled Americans. The schemes have been widely scrutinized for unscrupulous business practices. More than 80% of donors were “animals” – unreachable, offline or unavailable for meetings.

In a 2020 study, Louisiana academics studied this problem in Medicaid, the social insurance program for low-income and disabled people. Only 25% of the 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 able to make an appointment with 17% of the listed providers. A 2015 survey across three US cities found that 22% of the phone numbers for adult psychiatrists were incorrect and 21% were not accepting new patients.

“We are in a mental health crisis and health initiatives need to step up,” said Sue Abderhold, executive director of NAMI Minnesota, or the National Alliance on Mental Illness. He said the problem of the air network is, in part, a problem of manpower.

A recent ProPublica investigation found that, for many mental health providers, being in an insurance network is irrelevant. Low premiums and insurance policies, such as clawback provisions that allow insurers to go directly into bank accounts, make staying in-network unviable.

“As a result there are fewer doctors who are insured, which is a reality that affects patient access,” said London Breedlove, a licensed psychologist and director of professional affairs for the Washington State Psychological Association.

But you wouldn’t know that as a customer. If you have a business health plan and you go to your insurance website and say, ‘I’m looking for a provider’ and put in your zip code, it looks like there’s 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 grow even more by 2036.

“We see in our state a very high percentage of patients who have to go online to access important mental health resources,” Breedlove said.

For those receiving insurance, mental health providers are typically paid only $0.76 for every $1 paid to primary care, physical health providers.

Breedlove is advocating for a Washington state bill that would cap insurance reimbursement rates for mental health care to lower costs. With this change in the cost of living, he hopes that insurance will be more attractive to his colleagues.

“If you don’t have enough people in your network to have an adequate network, you have to pay them more than hire them,” Abderholden said. “When that starts happening, we will see better access because we won’t have people retiring. We will have people making enough money to pay off their student loans. ”