A “ghost network” is a network with lots of clinician names, but policyholders can’t access services. Payers keep ignoring the elephant in the room, the main reason why ghost networks exist: low reimbursement. Even after all these years in this industry, their avoidance never fails to surprise me.
While all payers are guilty of ignoring the elephant to some extent, the undisputed master of it is Anthem-NY. New Yorkers are fed up with not being able to find therapists who participate with Empire (Anthem) BC/BS. Last October, a suit was filed alleging that Anthem’s mental health network in New York is haunted by ghosts rather than live therapists who accept new clients. And on May 1, it was reported that NY state employees had filed suit against Carelon (owned by Anthem), with the same complaint.
In the Big Apple, where Google says the average rents for a one-bedroom apartment range from about $5,000/month in Manhattan to an “affordable” $2,800/month in Queens, in-network therapist reimbursements are shockingly low. I looked at some data from 2016, and the master-level reimbursement rate from Beacon (now Carelon) for state employees was $67 for a 90834. To have kept up with inflation, in 2024 that reimbursement would have needed to be $85. The actual in-network reimbursement rate at the end of 2024 from Carelon for state employees? $67.
And if you think that’s bad, the state employees are lucky compared to the NYC employees. City employees, whose mental health insurance (Emblem Health) uses Carelon for behavioral health, have to compete for in-network master-level therapists who were paid $55 for a 90837 at the end of 2024. The rate for this same code in 2016? You guessed it: $55.
Sure, some therapists can fight the good fight and increase their reimbursement. But in a crowded environment like New York, it’s much more difficult. Therapy-platform penetration is high, as is the number of therapists. Insurers can get by with ignoring the elephant because there are enough young and hungry new licensees who have to eat and who don’t have the reputation or experience to command high self-pay rates.
So is it shocking that the lawsuits are proliferating? Not in the least.
Ignoring the elephant has turned Anthem-NY into the Hotel California
In 1976, The Eagles sang about the Hotel California, where “You can check out any time you like, but you can never leave.”
To me, that perfectly describes the current Anthem ghost network in New York. I’m occasionally contacted by therapists who’ve tried to resign from that panel but are unsuccessful.
How hard is it to resign from a panel!? Just send a letter!
Letters are “never received.” Or they’re received and responded to. The responses will state that after your contractual 90-day notice period, you’ll be out. But, mysteriously, after 90 days, you’re still listed in the directory as “participating.” Even though the No Surprises Act says the directory is supposed to be updated within 2 business days of a provider making a change to their information.
Then when clinicians try to resolve it, they get stuck in an endless feedback loop of long holds, letters/emails with no response, excuses, and erroneous instructions such as“sorry but you can only resign at the end of the calendar year.” Apparently,“you can only resign at the end of the year” is a common occurrence, and this little shenanigan has been going on for quite a while.
And now, there’s a new twist. Nationwide, and not only with Anthem, clinicians who are joining insurance panels are now being presented with newer versions of insurance contracts which contain terms like “this is a 3-year contract.” What that means is:
- You must stay for 3 years
- Your reimbursement rates are locked for 3 years and can’t be increased (even though the payers are perfectly free to increase premiums…)
Note that this only applies to private practices, not if you join via the mega-therapy platforms. Discrimination much?
So will the law help since clinician advocacy efforts can’t?
That remains to be seen. But as a result of ignoring the elephant in the room, Anthem has a lot of cash with which to pay lawyers. In the case filed last October, they’re putting up legal roadblocks.
I don’t have the data to know for certain, but from a common sense perspective, it sure seems like paying clinicians well would be cheaper than ignoring the elephant – or paying lawyers and court costs, with associated bad publicity, government regulatory fines, and potential loss of business to competitors. But what do I know? Maybe not – because then if there were enough in-network providers, they might actually have to pay more claims. Horrors!
In the meantime, if you’re struggling to get removed from a panel, or with any other insurance, practice management, or reimbursement issue, I can help.
