After three weeks of frustration, Griswold paid for an out-of-pocket appointment.
It was a textbook case of a “ghost network”: a commonly used term by professionals for a panel of medical providers who for various reasons aren’t providing. Patients and doctors have been complaining about ghost, or “phantom” networks for more than 20 years. The problem is particularly pernicious in mental health care, and by many accounts has gotten worse in recent years — and amid the mental health crises of the pandemic — as increasingly desperate callers get ghosted by a range of specialists.
“For some individuals who are barely holding on, one call is all they have,” says Heidi Strunk, chief executive of Mental Health America of California. “It’s taking everything they have to make that one call. So if someone isn’t answering, we lose the opportunity to help them and they sink deeper into their depression. It’s no exaggeration to say lives have been lost because of this.”
‘Egregious and deceptive’
San Diego City Attorney Mara Elliott filed lawsuits last summer against three large insurance networks, accusing Kaiser Foundation Health Plan, Molina Healthcare of California and Health Net, a subsidiary of Centene, of violating state and federal law in creating “formidable, dangerous, and unlawful barriers to patient care, harming public health and California health insurance markets.”
Kaiser, with more than 9 million clients, “is among the worst actors in California” in terms of the inaccuracy of its provider networks, says the lawsuit against that firm. The lawsuit contends the plan has more than 30 percent inaccuracy rates in its mental health care directory and an overall inaccuracy rate of 19.14 percent.
Molina, with nearly 1 million enrollees, has had, according to the lawsuit, “a truly staggering inaccuracy rate of over 80 percent for psychiatrists” and an overall inaccuracy rate of more than 50 percent. Health Net, with more than 2.3 million enrollees, had an overall error rate of 18.13 percent, that lawsuit said, with nearly twice that for psychiatrists.
“It’s an egregious and deceptive policy we’re not willing to tolerate, that can make difference between a person being healthy and not healthy,” Elliott said in an interview.
All three lawsuits charge that the health firms persist in “publishing and advertising provider information known to be false and misleading.” The result is particularly harmful to people with low incomes and with high need for medical services, and in particular for women who “disproportionately bear the burden of ghost networks because they are more likely to perform unpaid care work for others,” the lawsuits say.
Kaiser Permanente spokesman Marc Brown says in an email that the plan’s leaders “strongly dispute” the lawsuit’s claims. Citing the “overall national shortage of therapists,” he says Kaiser is hiring specialty mental health clinicians at a rate outpacing membership growth while “optimizing clinician schedules to maximize patient-facing time.” 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 suit, all three firms challenged the city’s authority to hold them accountable, since they were being regulated by the state.
They all pointed out some of the difficulties in keeping accurate and up-to-date directories when, according to Molina’s response, “providers regularly (even daily) have updated information, or enter or leave Molina’s network . . . without providing advance notice to Molina, or any notice to Molina at all.”
Elliot described her lawsuit as unprecedented, saying she filed it because state regulators weren’t adequately addressing the problem. California gives some city attorneys authority to sue on behalf of residents throughout the state.
Elliott says she had filed the lawsuit because state regulators weren’t adequately addressing the problem. California gives some city attorneys authority to sue on behalf of residents throughout the state.
“I was astonished to see how egregious the problem was,” says Elliott, despite claiming that she had encountered illusory networks herself several times as the mother of two teens.
“I just hadn’t looked at it through my city attorney lens,” she adds. “Most of us are so busy that we just keep making the calls until we eventually get some kind of response.”
Being able to keep calling is a “privilege” for those with the time to do so, notes Strunk, who says the ghost networks therefore discriminate against people who cannot afford to keep pushing, never mind pay out of pocket in 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 at Berkeley, Abigail Burman proposed the legislation for an assignment in one of her classes. Her professor, Erin Bernstein, passed it on to a colleague at the San Diego Attorney’s office, while Burman fleshed out the proposal in a paper published in the winter in the Yale Law and Policy Review. In that paper, Burman charges that the ghost networks are a worrying sign of the overall failure of lawmakers and regulators to protect consumers.
Burman said she couldn’t comment because she was clerking for an appellate-court judge and had to abide by prohibitions against judicial involvement in political issues. But Simon Haeder, an assistant professor of public policy at Pennsylvania State University and longtime expert on ghost networks who worked with Burman on her paper and then with the San Diego Attorney’s office, said that Burman “collected the data they’re using and wrote the law review article that’s the foundation of the case.”
Griswold said part of the problem with all those non-providing mental health providers owes to insurance firms’ low reimbursements for such care. Insurance firms, on average, pay her only half of what she typically receives from cash clients, she said. As a result, Griswold and other therapists say they may stay on the providers’ lists as a Plan B for when cash-paying patients may be scarce, but hold out for higher rates if possible.
Griswold filed a grievance with the California Department of Insurance against Kaiser, the insurer for her husband’s company in 2012. But the case was never settled. “Two weeks after I filed it, my husband’s company decided to switch plans,” she says. “They told me it was because they’d gotten so many other complaints.”
Don’t let the phantoms bring you down.
- Take careful, thorough notes any time you need to search for a provider.
- If you’re calling numbers on a list, don’t wait for one provider to call back. Call and email many at once for the best chance of a quick response. Write a few paragraphs outlining what kind of care you need.
- If you or a member of your family is in a crisis, ask your plan for help finding a provider. If your plan won’t help, turn to the human resources department where you work, if there is one.
- If you’ve made a good-faith effort to find someone and can’t get help in a reasonable time from the list provided, don’t just give up and pay out of pocket. Ask your plan for a “single-case exception” — an option many health-care consumers are unaware of. It allows your insurance plan to reimburse an out-of-network provider while you pay no more than a co-pay.
- You can also request a single-case exception if the only available provider is a long distance from your home or doesn’t practice the specialty you need.
- Also ask for an exception if you’ve been allowed to see an out-of-network therapist online or by phone during the pandemic but now the plan has stopped covering it.
- To contest a lack of coverage either for medical services needed or already provided, you must first appeal directly to your health plan. With a private plan, you must file within six months of care being denied. The insurer must make a decision within 30 days if your appeal is for a service you haven’t received, and within 60 days if it is for a service already received.
- If you don’t get a satisfactory decision on an appeal, take your case to the government agency that regulates your insurer for an independent review. The customer service line of your health plan should tell you which agency to call. Don’t wait 30 days if there’s a health crisis. Contact your regulator immediately.