Vaughn McLaughlin, a New York City therapist, wants out of his Empire Blue Cross insurance contract. He wants out really badly, but he says he can’t get out. And he’s not alone.
McLaughlin has been working on ending his contract with Empire since May 2022, and intensively since March. He’s now been told he can’t leave until the end of the year.
A Long Island therapist we talked to has been trying to leave Empire since November 2021 – well over 18 months, and she’s only now thinking that maybe she has managed to leave.
Their stories of repeated requests to leave a contract, long phone hold times, no response to emails, and appeals to the New York State Department of Financial Services are full of sad detail. And their stories don’t begin to represent the problems of patients, who will be struggling with insurance themselves – who is in network? What will the insurer pay? And how much time do I have to spend on hold to resolve this?
Our examples of insurers holding therapists unwillingly in contracts are all related to Empire in the New York City area. When we put out a call for examples via a professional group, we had responses from more people than we could possibly talk to; we did not hear anything about similar problems with other insurers.
We did not call out to patients, because it seems obvious that patients will be less eager to talk about this topic, but it seems clear that their problems are vast – after all, each therapist has many patients, and those patients may not all have Empire but some certainly do.
Is this all of Blue Cross or just New York City? Our examples are from Empire — New York City and downstate therapists, but we are not sure that’s exhaustive. Empire covers 28 eastern and southeastern New York counties.
‘Fighting tooth and nail’
McLaughlin said he has been a member since 2017. He started thinking of leaving in spring of 2022, and had a hard time getting a firm answer about the departure protocol, he said. He then announced he was leaving the Empire plan in March 2023. He said he has been “fighting tooth and nail” to leave. He told his clients he was leaving, with an effective date of the end of June, and told Empire also, following what he understood to be the protocol of a 90-day “continuation of coverage” withdrawal period after his declared date, to give patients a chance to re-situate themselves.
“I finally got something in writing that says, ‘Yeah, your contract is up, we’ve made a note of it, your last date is July 1,’ ” he said in a Zoom interview on June 20. “But then last week, I got a letter from somebody else. And I don’t even know who this person is. I had to Google him. He doesn’t have any contact information. It’s just a form letter. It says ‘Based on the terms, the earliest termination we can accommodate is December 31.’ “
This letter said the only way he could resign was to tell them 60 days before the end of the calendar year, meaning he’d depart at the end of the year, and that this clause was in his contract. (He did not originally have a copy of the 2017 contract, he said.) He has heard from other clinicians that they were allowed to go without this 60-day end-of-year notification, and he said “the inconsistency in that is making me furious.”
In frustration, he said, he went to Twitter, and got a response from the legal department that his network rep would respond, which she did, saying, “O.K., we will handle your request.” But then he didn’t hear from her again, and instead received the letter citing the end of the year as the end date.
He thinks he might be in insurance fraud territory, he said, because he told his clients he was leaving, and is now being told that he has to stay.
“Some of these clients are going to go to clinics, and some of them are planning to stay with me. If I continue to see these people, and I don’t bill their insurance, I can lose my license for that. That’s insurance fraud when you take money from somebody, right?”
An unexplained rate drop in fall of 2021
A licensed clinical psychologist in Long Island had an even more complicated story. She said she had been under contract for $95 a visit, and then suddenly, in the fall of 2021 — with no notification – she started getting paid only $80. (She spoke on condition of anonymity, saying she is afraid of “retaliation” from insurance companies.) She spoke with a representative and asked for a fee increase, and was told she would hear back “in three to four months.”
“This would mean that I would keep seeing patients at a rate I did not agree to,” she said. “It’s really not the patient’s fault, and you can’t abandon the patient. So you have to continue at the lower rate.”
The Empire rep she spoke to told her she had to talk to someone else, she said in a Zoom conversation. So finally, in February 2022, she spent four and a half hours over two days making eight separate phone calls on the matter, being transferred from person to person, getting disconnected and so on. In March, she said, she asked again for a fee increase, and was told it would be three or four months. “I asked can you expedite? I have been asking since November,” she said. “In May, I reached out again and asked why they had decreased the fee, and at that point I was told there would be an across-the-board rate hike in 2022, and that I would need to talk to the claims department.”
When she asked again, she was told that Empire’s behavioral health division was merging with Carelon, and that her contract would be assigned to Carelon. Carelon is a rebranding name that Blue Cross – which rebranded itself as Elevance in mid-2022 – applied to all a range of its healthcare services brands.
Healthcare Finance wrote in mid-2022: “Anthem has also announced the launch of healthcare services brand Carelon, which, over the next two years, will consolidate its existing broad portfolio of capabilities and services businesses. … Carelon services range from research to integrated whole-person care delivery, pharmacy, behavioral health to digitally enabled solutions.”
In September 2022, she said, she asked to be disenrolled from all Blue Cross plans that paid $80, but was told that she would instead be disenrolled from all Blue Cross Blue Shield plans. She rejected that because she didn’t want to leave patients high and dry. She then asked about the fee increase, but was told that there would be one coming at the end of the year. The fee increase never came. In February 2023, she was told that her contracts were going to be assigned to Carelon.
She said she told them she didn’t want her contract to be assigned to a new company. Then, she said, she was told that the only time she could withdraw was within 60 days of the end of the calendar year.
She consulted a lawyer, who suggested that she investigate the company’s policies, and she decided that Empire was indeed violating their own policies. She continued to refuse to allow her contracts to be assigned, and eventually resigned from the network completely. She is now no longer taking any Blue Cross Blue Shield clients – after a year and a half.
Is this unusual? Yes, she said, she had no trouble resigning from Cigna or from Beacon Health Options, but Empire was very different.
Empire ‘difficult to deal with’
Lynne Spevack, a licensed clinical social worker who is a psychotherapist and practice building consultant in Manhattan and Brooklyn, said she is not in any insurance panels – all her patients are private pay. She offered to give the “big picture” because in her work as a practice consultant, she hears about difficulties with insurers.
Empire Blue Cross in the New York City area has long been “difficult to deal with,” she said. “They make themselves inaccessible, and they’re hard to get in touch with. This has been true for decades. The thing that is new is that in the last two years, roughly, they are not allowing folks to terminate, or making it very difficult for clinicians to terminate, by not responding to emails and requests, or giving one set of instructions and then someone else says ‘you didn’t do it right.’
“People request a confirmation that they have been terminated, and they won’t do that.”
They are “at best slow-walking the terminations, and at worst just not doing them,” she said. She is seeing clinicians writing on listservs asking for advice – with suggestions of different contacts, or complaints to the Department of Financial Services.
A therapist shortage might also be a factor, she said: “Particularly last year, therapists were in huge demand, certainly in New York City. I think that emboldened a lot of therapists to decide ‘the hell with these insurance companies — I’m going to switch to private pay.’ And that may have accelerated the problem.”
Before the pandemic, in-network therapists were hard to find
What was true before the pandemic: A great deal of therapy was done on a cash basis. We started noticing this around 2013, as we learned about the healthcare system. Other services – an MRI, your cancer treatment — were typically covered by insurance. But therapy, seemed to be frequently on cash. Patients would tell us there are not enough providers in network, so they wound up paying cash or going without. (This is also a factor in the rise of online therapy options.) It seems clear that the pandemic has caused worse mental health problems nationwide, and so demand may be even stronger for in-network providers.
McLaughlin said he suspects he is part of a “ghost panel” – when an insurer says it has a panel of providers, but they are not really in network. The size of a panel is a selling point for an insurer, he said; if the insurer has 100 therapists, that’s a better sell than having 10 therapists.
Spevack also speculated on the ghost panel topic. “There needs to be a certain number of behavioral therapists in relation to the number of insureds. I don’t know the details, but I think this is their way of making it look to whoever the regulators are like they have sufficient panels. If they keep people on the panel, when they’re asking to be terminated it, it makes the panel look more robust than it really is. What a lot of therapists are asking is, well, why don’t they just do better and, you know, get more people with carrots? Offer a higher rate?” But of course that would cost money.
The Biden administration on Tuesday moved ahead with new rules meant to push insurance companies to increase coverage of mental health treatments. The new rules, which will need to go through a comment period, are intended to make sure that insured people have the same access to mental health care as they do to physical health care. The proposed rule changes to the 2008 Mental Health Parity and Addiction Equity Act are intended to improve access, including keeping insurers from using prior authorization and narrow networks to limit mental health treatment.
Spevack also said that there is now less of a stigma about therapy and more demand. That, coupled with the fact that managed care payments for behavioral health have been more or less stagnant since the 1990’s, she said, has created less of an incentive for therapists to stay in network. Stagnant pay means your income doesn’t stay up with inflation, which needs to be considered as far as a practice’s fees for office space, goods and services and health insurance for the therapist, she noted.
To be sure, a lot of medical specialties are encountering shortages. It’s hard to get a doctor’s appointment for a lot of people – wait times are long, and frustrations are high, with doctors resigning or switching to different ways of practicing.
Spevack said she had heard very few complaints about contract withdrawals for other insurers.
Two open complaints
In response to an email to the Department of Financial Services asking if there had been any complaints, and what recourse therapists might have, the department sent an email saying, “The Department currently has two open complaints from therapists regarding contracts with insurance companies. Insurance Law does include procedural requirements upon termination of a contract with a provider, such as notice requirements and right to a hearing.“
When I asked what insurance companies were involved, they suggested that I file a Freedom of Information request, which I am doing.
Several requests for comment to Empire went unanswered.
Navigating insurance for therapists
Barbara Griswold, author of the blog “Navigating the Insurance Maze,” and the book of the same name, is a therapist who helps other therapists with various aspects of the business of a practice, especially insurance. She has been hearing from therapists who are having trouble withdrawing from health plans.
One therapist had been told that they could not leave the plan until the end of the year, even though their contract says they can give 30, 60, or 90 days’ notice, she said. She herself asked to resign from Beacon’s Carelon plan but was told that she had been terminated from all Blue Cross and Carelon plans, she said.
She said it has long been true that bureaucratic delays and reports of lost mail requests and similar events, greet a request to leave an insurer. “But I’ve really never seen what’s happening now, which is actually getting a letter back saying, ‘well, we’ll think about it,’ ” she said. “That’s not in my contract. You don’t get to think about it, you need to process my request.”
Griswold said the problem may be may be due to complications inside health plans like Empire, rather than a deliberate attempt to make it difficult for therapists to leave. She says these companies have been overwhelmed by calls and emails since the pandemic, and the companies may be short-staffed and often the staff is not well-trained.
Griswold recommends that therapists who are having trouble withdrawing from Blue Cross Blue Shield keep a record of all their communications with the company. She also suggests that they contact their state insurance commissioner or the department of insurance if they are unable to resolve the issue. Some therapists have found resolution by contacting a lawyer, she said.
The whole thing is puzzling, she added. Blue Cross is well-known for turning clinicians away from their network, she said. Insurers try to keep their network small, because every new provider needs to be vetted for education, license and so on, she said.
“Their goal is keep the network as small as possible. So if I were going to call right now and try to join Empire, they probably would tell me, ‘No, we’re full.’ They turn away perfectly good providers. You would think they would want the most ample network possible. But no – there are lots of people out there who can’t get to see a network therapist because there are not enough on the panel. The ones who are on the network are full, because there’s such a high demand. They are creating a lack of network providers. This is a cross country issue.
Months and months
Patricia Galiotos, a psychologist in private practice in New York City, said she has been a member of the Blue Cross panel since 2017. She said she had tried to resign for several months. Noticing over the last year in the professional listservs she is on that people had difficulty in resigning, she said, she prepared by collecting from colleagues names of contacts.
She set forth to resign in February, she said, assuming there would be a 90-day waiting period, as stipulated on the Empire site. She began emailing to a contact she received on a listserv, and also addressed the same message to the provider services person on the website. She sent faxes and emails, she said, with no response. In April, she emailed again, explaining that she was planning to leave and wanted to tell her clients that she would be out of network. Finally, in early April, she got an email response from someone saying she was a colleague of the person Galiotos had first emailed, collecting details like her provider number, her exact date of departure (they settled on April 15, which would then be followed by a 90-day waiting period). And she waited and waited and waited.
“When I saw that it wasn’t being processed correctly, I felt helpless – I felt a total lack of control over how it would be fixed,” she said. “I was getting no response.” She started all over again and emailed the same five people.
Eventually, she said, she took the advice of people on the listserv and made a formal complaint to the Department of Financial Services website. Ten days later, while she was in an airport, she got a call from Elevance – this is the new name of the Blue Cross parent company of Empire — with one message saying that the behavioral health entity had been transferred to Carelon.
Among people she knows well, she said, one person resigned from Blue Cross several years ago with no problem. Another person, more recently, tried to resign but was told “sorry, you are part of Carelon, and so you can’t resign until the end of 2023.”
She said she still has not received confirmation that her resignation has taken place; last week, she said, she was told one rep could see a request had been made, but that “I’m still showing up as active in the system.” She is still getting claims processed as in-network, she said.
A two-year struggle
An upstate psychotherapist described a two-year struggle to separate herself from Empire, complicated by the fact that a previous employer, as she was leaving the practice, agreed to do the disenrollment and said they had a confirmation – but apparently it was not fully effective.
She learned this as she and a client, who lives in another state, with Blue Cross insurance through her employer, tried to send in bills for reimbursement. Some seemed to get lost, she said, then some went through. “And I would get something on Empire letterhead marking me as an in-network provider,” and she would be forced to go back to the call center.
“The number of hours I have spent calling Blue Cross in this state, in the state where she has lived, the number of times she has called…” the therapist said in a Zoom interview, describing calling the 1-800 line and being on hold for 45 minutes, reaching call center employees who were apparently not allowed to deviate from a book of approved responses other than to say “re-submit the claim” – and often a noisy call-center background of hundreds of other people. “Even though I spent an hour and a half on this call, I got nothing,” she said of one experience.
The sum total, she said, is that the claims from the other state are passed back to Empire, where she is being marked as in network, and “which is an insurance my client doesn’t have.” She has received checks for payment that she never cashed, and demands for repayment as well. “Meanwhile, Empire is getting paid all the time, by employers and through payroll deductions,” she said.
While her hours and hours of problems are infuriating, she said, “The client who has been most impact is owed thousands of dollars. She has been paying me as out of network since 2021. She thinks that she has pretty good coverage, but she has yet to get any reimbursement. I am licensed to practice in that state, but it seems to have bamboozled them as to whether I count.
“I feel mostly bad for my client,” she said. “Therapy is a really major investment. She is doing wonderful, wonderful work. She is in it for the long haul – and she is paying for benefits that she does not have.”
What can you do?
Clinicians:
Clinicians told us that they spent hours on the phone trying to withdraw from networks.
Some said they had hired practice managers or billing services to help them cope with these problems.
Many people told us that they had turned to online listservs or other similar trade groups to document their problems and seek help from peers.
Other courses of action: Filing a complaint with the insurance regulators, in New York with the Department of Financial Services.
Some clinicians have reported to us that they contacted lawyers to help them leave.
Patients, or as we like to call them, people:
Appeals to your insurance company may bear fruit, though we have heard a lot of the “yes, we have an in-network therapist – she is 300 miles away and has one opening in December – would you like it?”
The Consumer Finance Protection Bureau has a complaint system.
We have learned in many years of immersion into the healthcare marketplace that many therapists decided long ago not to accept insurance payments. If you’re unsure about who accepts what, the practice’s website may be informative.
Psychology Today has a find-a-therapist function, with therapist profiles including, quite often, the insurance they take and a statement of hourly cash rates. You can do a zip-radius search to find therapists close to you.
Online options:
Online therapy options from companies have grown, especially with a rush of venture capitalist funding and a surge in demand for online medical treatment driven by the pandemic. Betterhelp is one of the biggest, describing itself as “the world’s largest therapy service. 100% online.”
While online options have grown, there have also been a number of complications; online provider Headspace, for example, recently laid off a number of employees. Another online provider, Cerebral, revealed that it had given patient data to advertisers and to big platforms like Meta, Google and TikTok. Many users also reported concerns about the treatment Cerebral gave, and about its assessments of therapy providers.
“Digital mental health companies have struggled over the last year,” Behavioral Health Business reported recently. “Virtual providers Talkspace, Cerebral, Eleanor and Foresight have all announced layoffs. Additionally, behavioral health tech company Mindstrong shut down earlier this year.
“Investors have also begun to pull back on funding virtual behavioral health companies. Behavioral Health funding decreased by 56% from 2021 to 2022, according to a report by San Francisco-based digital health venture capital and advisory firm Rock Health.”
