Important Reads: New Reporting Details Ghost Networks and Fighting Denials
Navigating behavioral health care in the United States can feel like a cruel game of hide and seek. Millions of Americans, already struggling with mental health and substance use issues are forced to confront a system that dangles the promise of in-network therapists and doctors. But when they finally reach out for help, they all too often discover a grim reality: Many of the providers listed in their insurer’s directory simply don’t exist or aren’t accepting patients. This isn’t a minor oversight; it’s what’s known as a "ghost network" and it leaves countless people stranded when they need care the most.
Big health insurers like UnitedHealth, Cigna and CVS/ Aetna, of course, know about this problem – I did before I blew the whistle and left the industry in 2009. Insurers know this is a big problem, but they have little incentive to fix it. Why? Because ghost networks are profitable.
When a health insurer lists hundreds of in-network providers, whether they’re actually available or not, it creates the illusion of a robust, well-functioning network. This allows insurers to check regulatory boxes and claim they’re offering comprehensive mental health coverage, but the reality is completely different. After all, if fewer people can access care, fewer claims are filed. For insurers, that’s a win.
What’s particularly scary is how ghost networks push individuals toward out-of-network care, where they often face exorbitant out-of-pocket costs. Desperate patients, after weeks of trying to find an in-network provider, may be left with no choice but to see someone outside their plan, footing most or all of the bill themselves. And when you’re facing depression, anxiety or substance use disorders, the added stress of surprise medical costs can be devastating.
Over the past several weeks I’ve worked with reporters at ProPublica and TIME on stories that focus on ghost networks and treatment and claim denials and what actions patients can take.
A Story of Denial
ProPublica’s Max Blau details the harrowing story of a young Arizona man’s failed attempts to find a behavioral health doctor. The story about the incredible hoops and dead ends Ravi Coutinho’s experienced because of his insurer’s inadequate provider network and unhelpful customer service reps is heartbreaking and maddening. His story, sadly, is all too common because of the many barriers health insurers have erected that make it nearly impossible for insured patients to get the care they so desperately need, especially from mental health professionals.
In a companion piece, Struggling to Find an In-Network Mental Health Provider? Here’s What You Can Do, Blau notes advice from health insurance experts, clinicians and advocates to explain how you can navigate the illusion of access and options set by health insurers.
Blau opens up his piece like this:
It’s hard to know if your health insurance plan is as good as advertised. You pay a monthly premium to access a network of health providers. But call the numbers in your provider directory, and you’re bound to find ones who can’t — or won’t — see you.
These errors are at the heart of a ghost network. Some providers have moved, retired or even died; others left insurance networks because of low pay and intense scrutiny. Even though these providers no longer accept your insurance, their names may remain in the directory. When that happens, policyholders are left to believe that the plan has more options than actually exist.
“Being a squeaky wheel is important”
In Jamie Ducharme’s September 6 piece for TIME, consumer advocates Jeremy Gurewitz, Diane Spicer and I explain how to fight back against denials and delays imposed by big health insurers. Fighting back includes informing yourself about your case; filing an appeal with your health insurer; and (in my opinion, most importantly) raising hell.
When a patient is met with a denial, I told Ducharme:
Never take ‘no’ as a final answer, ever. Insurance companies are expecting the people enrolled in their health plans to just accept whatever they decide to do because [pushing back] is complicated. It’s a burden. It’s a chore…
Being a squeaky wheel is important.
I’m encouraged that more and more reporters are paying attention to the growing crisis of people who have health insurance, pay dearly for it in premiums and out-of-pocket requirements, but still cannot get the care they need. Let’s hope our policymakers and employers are paying attention at long last.
This is an important issue, and it's not just mental health care. Ghost networks include (or don't include) all kinds of practices.
This is a great report, and as one who dims fighting against the big insurance carriers this should motivate more American Seniors who are on Medicare (dis) Advantage.,write to your stat’s insurance commission, and other local and State politicians to get them upset enough to start bringing the issue of these ghost in-network lists up as a serious impediment to quality of care and the promise of a dignified retirement and life in our civil society. Thr greed and avarice of the big insurers who are motivate only by profit need to be excluded from offering insurance policies to Americans. Congress has to stop pandering to corporate interests and protect and defend the rights of their human constituents, NOT corporate people in return for campaign donations. The system is SICK and needs prompt action from our duly elected officials at all levels of Government. Apathy exists because the American people have been lied to by the Insurance Lobby and its propaganda campaigns.