“I’ve been seeing my cardiologist since 2016 and insurance company’s website shows he is in my network but recent referral is denied and the denial letter says he is out of network,” the Tweet said.
Another tweeted: “Companies that are dedicated to help you navigate your healthcare insurance benefits struggle just as much as you would. Me- “Is this provider in my network?” Them- “One moment, let me check. Actually, let me place you on hold.” [15 mins later] Them- “So we’re not actually sure…””
A Colorado therapist told us she was “paneled by surprise” — suddenly receiving a flood of patients who said they had been told she was in network, without having received a contract. A New York area therapist told a similar story.
What doctor is in your network, and who’s out? And if you’re a doctor, are you in or out? And how can you tell?
The in-network and out-of-network muddle is getting more muddled, from all reports. It has been confusing since we first started studying the healthcare marketplace in 2011, and yet it never seems to improve.
This came up in the context of our recent post about therapists who have been unable to terminate their Empire Blue Cross contracts, despite repeated efforts.
It seems clear that the upheaval in the system caused by Covid, including deaths and retirements and departures of doctors, has complicated things — but this problem well predated Covid.
In a timely note, the Biden administration noted the problem of in-network and out-of-network mental health providers just last week, proposing a rule to increase access to mental health care by requiring plans to take action if they are providing insufficient access to in-network care.
‘Paneled by surprise’
The Colorado licensed marital and family therapist said she applied to be on the Blue Cross panel in 2020, but got no contract, no rates and no confirmation.
Then, in 2023, she said, she got “a tidal wave” of calls asking for in-network appointments, saying she is listed as an in-network provider.
“And when I say ‘tidal wave’ i mean at least 2-3 phone calls per day,” she wrote in an email. “And people were desperate, ‘I have been calling everywhere but can’t find a therapist.’ I tell them that I’m not on the panel and they move on.
“If I initiate a therapeutic relationship it would be irresponsible because I’ve never seen a contract. The waiting list in my area is about three months for a BCBS therapist. I called one place and they told me they’re not even accepting new patients for their waiting list.”
She said two professional groups she is on, one in California and one in Colorado, “both have posts from people mentioning being surprise paneled by BCBS.” (She spoke on condition that we not use her name, to avoid further conflicts with insurers.)
When the calls started coming in, she wrote, “I got a call from a BCBS to confirm whether I was accepting new clients. When I asked ‘what the actual fuck’ the representative told me they found me on a list of in-network providers. she told me she would not help me figure this out. during this process i even got connected to a rep who was drunk.”
“I wanted to know what my contract rate was so i tried to get in touch. As you know, this is impossible. …You cannot get through to a representative without a valid member ID, and since i did not have any clients i did not have one. I was not about to take a client without viewing my contract or knowing even what my contract rate was. I used my own member ID (because i have BCBS) to get through their system. BCBS told me i had been credentialed. I said ‘how do i get uncredentialied.’ A long run around. there is a form online you can fill out to get uncredentialed. I filled it out and they said it will take 90 days. (this was feb 2nd of this year). I got an email in march from the email provider.datamgmt@anthem.com saying they confirmed termination.”
Blue Cross did not respond to a request for comment.
Why does this happen?
So why is it so hard for the insurance companies to make an accurate in-network list? After all, it should be a matter of contract law: They have a contract with a doctor, put the doctor on their network list, and then check the list periodically to confirm that a doctor is still under contract and thus in the network, right?
Sometimes the provider is in network for some plans and not others — yes, for Blue Special Premium PPO, but no for Blue Garden Variety HMO. You would think, again, that they could keep records on this, but sadly no. Other reasons: The provider is in network for some services and not others, or the contract terminated and the directory is not updated.
It is somewhat easier to understand if a public-facing directory is out of date, since they may have decided not to update on a daily basis. But if you call the Blue office and ask, in real time, the answer should be correct, shouldn’t it?
Promises of higher pay
Lynne Spevack, a licensed clinical social worker who is a psychotherapist and practice-building consultant in Manhattan and Brooklyn, said she has heard of such cases.
“There’s a longstanding problem with Multiplan (and perhaps other companies, representing insurance plans) that use deceptive practices to enroll clinicians,” she wrote in an email. “Multiplan reaches out to clinicians, promising to pay the client more quickly if the (out of network) clinician agrees to negotiate the rate; my recollection is that some clinicians who have taken the bait have found themselves enrolled in panels when that was not their intention, and Multiplan then drags their feet about correcting the problem. “
Barbara Griswold, author of the blog “Navigating the Insurance Maze,” and the book of the same name, who advises therapists on business matters including insurance, said by email: “Yes, I hear this from time to time, but of course, they might have missed a letter from the plan that confirmed their acceptance into the network. But I certainly wouldn’t put it past a network to forget to send a therapist some sort of notification.
“A different way that therapists could get enrolled in a panel unintentionally happens when one health plan merges with another plan or ‘buys up’ the network, and suddenly you are on a network you may not have intended to sign up with (but in this case you usually get correspondence saying so). However, I will say therapists aren’t always the best at reading all their correspondence from health plans….”
Lack of oversight
Susan Null, medical bill advocate at Systemedic, Inc., in New City, N.Y., said “the issue, as I understand it, is that there is no oversight by anyone on the insurance companies to keep their provider lists current.”
“I always tell people who reach out to us about similar issues that if they find a provider listed as in network on their insurance portal, they should copy that screen with the date so that if reality shows something different, the person has proof and has an argument that they relied on this information to see the provider,” she wrote in an email. “That evidence would be significant enough to likely get their charges covered … but also likely after their having to go through a long fight. It’s just another example of insurance companies wielding their power and making a confusing system that much more unintelligible … if you can’t rely on the information that the insurer provides about your coverage, than who can you rely on?
“I truly believe the problem is that keeping those provider lists current is a monumental task, one that would cost them a lot of money. With no one penalizing them for not doing the job, we, the consumer, are left holding the bag.”
Update, Aug. 23: After reading this article, the Colorado therapist wrote back. “Susan Null’s advice is best-case-scenario,” she wrote in an email. “Insurance companies can and do change benefits in the middle of a plan year and there’s nothing you can do. Screenshot the benefits page, write down the exact time of the call confirming benefits, with the rep’s name that you talked to and the time, and there’s still nothing you can do. I’ve been quoted the wrong benefit info on the phone before and then gotten a claim back like, ‘the client owes you out of pocket for the full cost of every session you did for the last six months.’ I called and told them that a rep told me the benefits information, and the company said ‘yes, we listened to the call and what the rep told you was wrong. Too bad.’ “
Lack of supervision is a characteristic of the “network adequacy” conversation — whether a network is adequate or not. The Affordable Care Act required health plans to ensure a sufficient choice of providers, and to give information about those networks. But, Karen Pollitz wrote for Kaiser Family Foundation in 2022, oversight is lax to nonexistent.
“The federal government certifies QHPs offered in 30 federal marketplace states. Initially federal marketplace issuers were required to submit provider networks for CMS review and certain federal standards applied. Beginning with the 2018 plan year, the Trump Administration ended direct federal oversight of the adequacy of QHP networks, deferring to state oversight, accreditation by private organizations, or the issuer’s attestation. A federal court subsequently ruled this change was arbitrary and capricious, and as a result, federal oversight is scheduled to resume for the 2023 plan year.”
Surreptitious enrolling
Another therapist, this one from the New York City area, said she found an insurer who tried to “enroll me surreptitiously” in a network. She spoke on condition of anonymity to avoid potential “retaliation” by insurers.
Her patient decided to change to a different insurer, she said, and asked the insurer specifically if the therapist was part of the panel. They told her yes.
“And I said, ‘I am not part of that panel.’ And she said, ‘Oh, no, no, they said that you are’ I said, ‘Well, I can’t imagine how that could be true, but let me take a look. So she gave me the contact information, and I wasn’t.
“And then I got an email and some phone calls from the insurance company asking me to finish my application. And I had never started it.”
She said sometimes insurance plans will be acquired or change names, which can be confusing. But she was sure she was not part of the plan.
“You might, let’s say, get credentialed with United and United might have 10 different insurances underneath them, some of which you may never have heard of. And so when someone says, oh, you know, we’re re credentialing you for this plan, you might think, oh, it’s probably part of this other plan. It must be part of that group.”
She was sure that wasn’t the case in this instance, she said. But she did ask about the rates.
“I was told we don’t give you the rates until after you sign the contract, which is pretty standard. When you’re a new psychologist, and you’re just starting out, that’s what you do, because you need the business. Or if you happen to be not so new, but you just believe people should get health care, even if they can’t afford it. Then you’re staying with panels for the greater good.
“But yeah, when you get your contract, you’re committing to working for a price, of which you have no idea. I will tell you the last time I was presented with a contract like that, within the last year, I just said you guys are out of your minds. If you think I’m signing a contract for you, when I don’t know what I would be paid. It’s ridiculous. But they have all the power.
“And so you can decide not to join with the panels, but then your private practice has to be 100% private pay, which means a lot of marketing expenses. What they say is: If you want a busy practice, then you go with the insurance panels. And if you want to make more money, then you have a small practice and you have fewer patients who are private pay, but then you’re constantly having to chase new clients until you reach a certain place where everybody’s just referring to you because now your name is out there and people know you.”
Senate panel investigating
The American Medical Association president, Dr. Jack Resneck Jr., testified before a Senate panel investigating the problem this spring.
“’When directory information is incorrect, the results can be complicated, expensive and potentially devasting, especially to patients,’ Resneck told the Senate Finance Committee, according to an A.M.A. press release.
“’Inaccurate directories shift the responsibility onto patients to locate a plan’s network or pay for out-of-network care,’ added Dr. Resneck, who chairs the University of California, San Francisco dermatology department. ‘Patients are financially impacted and may be prevented from receiving timely care. Moreover, in the long run, continuing to allow inaccuracies makes it easier for plans to fail to build networks that are adequate and responsive to enrollees’ needs. Accurate directories are a basic function and responsibility of health plans offering network products.”
In 2022, federal law instituted new penalties for inaccurate network listings under the Consolidated Appropriations Act of 2021. But not much seems to have changed.
Group health plans, insurance issuers and providers are required to take specific steps to protect insured people from out-of-network bills. They must take specific steps to improve provider directories and bear certain costs when inaccurate directories cause patients to incur out-of-network bills.
Under the C.A.A., the database of in-network providers must be public; must have an established verification process; must have a response protocol for insured people’s phone queries and electronic queries; and other similar protections. The C.A.A. also requires that the directories be accurate.
At the Senate hearing on “ghost networks” in May, Committe Chair Ron Wyden discussed the bill he had introduced previously with Tina Smith last Congress to impose penalties on insurance companies.
Not a new problem
This is not a new problem. The city of San Diego sued Kaiser in 2021, saying that the insurers’ directories were false or inaccurate and confused consumers seeking in-network care.
The idea that someone would go to a doctor described as in-network and wind up with an out-of-network bill is, of course, one of the things the No Surprises Act was intended to attack. That of course is if you go to an in-network emergency room, say, and get an out-of-network contract emergency room doc. N.S.A. is supposed to end that.
But there has been no fix for the inaccurate provider directory problem, and that is what Wyden and Smith addressing.
It may also be true that a doctor is nominally in the plan, but is not accepting new patients. In 2016, The New York Times and Kaiser Health News collaborated on a story about the problem, leading off with a woman from Toledo, Ohio, who was signing up for a new insurance plan and looking for a primary care physician — but coming up dry in the insurer’s in-network provider listings. “Surprised that information about something so central to health insurance could be so poor, she contacted almost every primary care physician listed as accepting new patients in every local plan. More than three-quarters of those doctors in her part of Ohio were in fact rejecting new patients, she found.”
in 2019, Jack Turban, who was starting his training in psychiatry, took his professor’s advice and sought to find a psychiatrist, to understand the process better. In an article for Stat, he wrote: “I started calling a list of psychiatrists who supposedly took my insurance. Some of them were dead. Many weren’t taking new patients. Others didn’t take my insurance. I couldn’t find a single psychiatrist on the list to see me. It took months of networking for me to finally find a therapist. I later found out that my experience was commonplace, possibly deliberate, and that such inaccurate provider lists have a name: ghost networks or phantom networks.”
“My patients regularly tell me that this is not unique to Blue Cross Blue Shield and happens with most insurance providers. A 2016 survey by the Centers for Medicare and Medicaid Services showed that it’s also a problem with other medical specialties. The numbers, however, never seem as bad for other specialties as they do for psychiatry.”
His experience was similar to that in 2015 from a team of investigators on a National Library of Medicine study.
Posing as patients, “researchers called 360 psychiatrists on Blue Cross Blue Shield’s in-network provider lists in Houston, Chicago, and Boston. Some of the phone numbers on the list were for McDonald’s locations, others were for jewelry stores. When the researchers actually reached psychiatrists’ offices, many of the doctors didn’t take Blue Cross Blue Shield insurance or weren’t taking new patients. After calling every number twice, the researchers were unable to make appointments with 74% of providers on the list. In a similar study among pediatric psychiatrists, researchers were unable to make appointments with 83% of the providers listed as in-network by Blue Cross Blue Shield.”
In a 2018 study, researchers found that at least 52 percent of Medicare Advantage network listings had at least one inaccuracy.
