After three weeks of frustration, Griswold paid for an appointment out of pocket.
This was a textbook case of “ghost network”: a term commonly used by professionals to designate a panel of medical providers who, for various reasons, do not deliver. Patients and doctors have been complaining about phantom or “ghost” networks for more than 20 years. The problem is particularly pernicious in mental health care and by many accounts it has worsened in recent years – and amid the mental health crises of the pandemic – as increasingly desperate callers are ghosted. by a range of specialists.
“For some people who are barely holding on, one call is all it takes,” says Heidi Strunk, executive director of Mental Health America of California. “It takes everything they have to make that one call. So if someone doesn’t respond, we lose the opportunity to help them and they sink deeper into their depression. It is no exaggeration to say that lives have been lost because of this.
“Huge and Deceptive”
San Diego City Attorney Mara Elliott filed lawsuits last summer against three major insurance networks, accusing Kaiser Foundation Health Plan, Molina Healthcare of California and health neta subsidiary of Centene, of violating state and federal laws by creating “formidable, dangerous, and unlawful obstacles to patient care, harming public health and California’s health insurance markets.”
Kaiser, with more than 9 million customers, “is among the worst players in California” in terms of the inaccuracy of its supplier networks, the lawsuit against that company says. The lawsuit argues that the plan has inaccuracy rates of over 30% in its mental health care repertoire and an overall inaccuracy rate of 19.14%.
Molina, with nearly one million enrollees, had, according to the lawsuit, “a truly staggering inaccuracy rate of over 80% for psychiatrists” and an overall inaccuracy rate of over 50%. Health Net, with more than 2.3 million registrants, had an overall error rate of 18.13%, according to that lawsuit, nearly double that of psychiatrists.
“It’s a blatant and misleading policy that we are not prepared to tolerate, which can make the difference between a healthy person and an unhealthy one,” Elliott said in an interview.
The three lawsuits accuse the healthcare companies of persisting in “publishing and publishing provider information known to be false and misleading.” The result is particularly harmful to people with low incomes and high need for medical services, and especially women who “disproportionately bear the burden of shadow networks because they are more likely to perform unpaid care work for others,” according to the lawsuits.
Kaiser Permanente spokesman Marc Brown said in an email that plan leaders “strongly dispute” the lawsuit’s allegations. Citing the “overall national shortage of therapists,” he says Kaiser is hiring clinicians who specialize in mental health at a faster rate than membership growth while “optimizing clinician schedules to maximize time spent with patients.” Kaiser has also “significantly expanded” virtual care by therapists during the pandemic and is investing $30 million to help increase the number of clinicians entering the mental health field, he wrote.
Molina and Health Net representatives did not respond to repeated emails and calls. But in motions filed in response to the lawsuit, the three companies challenged the city’s authority to hold them accountable because they were regulated by the state.
They all pointed to some of the difficulties in maintaining accurate and up-to-date directories when, according to Molina’s response, “vendors have regularly (even daily) updated information, or move in or out of Molina’s network.” . . without giving any notice to Molina, nor any notice to Molina. »
Elliot described her lawsuit as unprecedented, saying she filed it because state regulators were not adequately addressing the issue. California gives certain city attorneys the power to prosecute on behalf of residents across the state.
Elliott says she filed a lawsuit because state regulators were not properly addressing the issue. California gives certain city attorneys the power to prosecute on behalf of residents across the state.
“I was amazed at how bad the problem was,” says Elliott, although she claimed she herself encountered delusional networks on several occasions as a mother of two teenagers.
“I just hadn’t looked at it through the lens of my city attorney,” she adds. “Most of us are so busy that we keep making calls until we finally get some kind of response.”
Being able to keep calling is a “privilege” for those who have the time to do so, notes Strunk, who says phantom networks therefore discriminate against people who can’t afford to keep pushing, let alone pay out of pocket. in the event of a crisis.
The origin of the San Diego lawsuit is as unusual as the lawsuit itself. As a law student at the University of California, Berkeley, Abigail Burman came up with the legislation for an assignment in one of her classes. His professor, Erin Bernstein, forwarded it to a colleague at the San Diego district attorney’s office, while Burman fleshed out the proposal in an article published this winter in the Yale Law and Policy Review. In this article, Burman accuses shadow networks of being a worrying sign of the general failure of lawmakers and regulators to protect consumers.
Burman said she could not comment because she was a clerk for an appeals court judge and had to abide by prohibitions against judicial involvement in political matters. But Simon Haeder, an assistant professor of public policy at Pennsylvania State University and a longtime expert on shadow networks who worked with Burman on his paper and then with the San Diego district attorney’s office, said Burman ” collected the data they use and wrote the law review article that is the basis of the case.
Griswold said part of the problem with all these mental health care providers not providing mental health services is due to low reimbursements from insurance companies for such care. Insurance companies, on average, only pay her half of what she typically receives from customers in cash, she said. As a result, Griswold and other therapists say they can stay on provider lists as a Plan B when cash-paying patients may be in short supply, but expect higher rates if possible.
Griswold filed a grievance with the California Department of Insurance against Kaiser, her husband’s company insurer in 2012. But the case was never settled. “Two weeks after I submitted my application, my husband’s company decided to change its plan,” she says. “They told me it was because they had received so many other complaints.”
Don’t let the ghosts get you down.
- Take careful and detailed notes whenever you need to research a supplier.
- If you’re calling numbers on a list, don’t wait for a provider to call you back. Call and email multiple times for the best chance of getting a quick response. Write a few paragraphs describing the type of care you need.
- If you or a family member are in crisis, ask your plan to help you find a provider. If your plan doesn’t help, contact your workplace’s human resources department, if there is one.
- If you’ve made a good faith effort to find someone and you can’t get help in a reasonable time from the list provided, don’t give up and pay out of pocket. Ask your plan for a “single case exception” — an option that many healthcare consumers ignore. It allows your insurance plan to reimburse an out-of-network provider while you pay no more than a copayment.
- You can also request a single-case exception if the only provider available is far from your home or does not practice the specialty you need.
- Also ask for an exception if you were allowed to see an out-of-network therapist online or over the phone during the pandemic, but now the plan has stopped covering it.
- To dispute a lack of coverage for necessary or already provided medical services, you must first appeal directly to your health insurance plan. With a private plan, you must file your claim within six months of the denial of care. The insurer must render a decision within 30 days if your appeal relates to a service that you have not received and within 60 days if it concerns a service that you have already received.
- If you don’t get a satisfactory decision on an appeal, take your case to the government body that regulates your insurer for an independent review. Your health plan’s customer service line should tell you which agency to call. Do not wait 30 days in the event of a health crisis. Contact your regulator immediately.
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