Lawsuit says "ghost networks" are denying Americans mental health care

Driving the news: Patients across the country have detailed accounts of buying health coverage only to learn that it didn't provide promised access to therapists and other mental health professionals.

• A higher proportion of counselors and therapists opt out of insurance networks than some other medical specialties, because health plans have the final say over who gets care and for how long and then delay reimbursements.
• Insurers have said they do their best to keep directories updated but depend on providers to keep information current. They have denied misrepresenting their networks.
• But unreachable providers pose major concerns at a time when the nation is grappling with a mental health crisis and patients are seeking timely help with substance abuse disorders or suicidal ideation.

Zoom in: The lawsuit filed against Anthem Blue Cross and Blue Shield this week framed the issue as a violation of the No Surprises Act.

• Two plaintiffs, including a federal employee and a parent filing on behalf of an 8-year-old child with autism, were both insured through Anthem when they say they tried unsuccessfully to use its online directory to find in-network providers.
• The adult plaintiff found multiple instances in which providers were listed with inaccurate telephone numbers, did not practice in the specialties listed or did not accept her Anthem insurance.
• She ultimately turned to an out-of-network provider within a reasonable distance of her home and received only a small reimbursement from the plan. The parent of the child had similar experiences.

State of play: The suit in U.S. District Court of the Southern District of New York alleges the network flaws violated a section of the surprise billing law that establishes provider directories exist to insulate consumers from large, unexpected medical bills.

• It also claims violation of federal mental health parity law and New York consumer protection law that requires insurers to keep their directories up to date within a month.
• "The misrepresentations and omissions made by the defendant constitute precisely the type of information upon which reasonable consumers would rely on in choosing a health plan," the lawsuit states.
• "Any disclaimers, such as 'the continued participation of any physician, hospital, or other provider cannot be guaranteed,' are woefully insufficient."

A "secret shopper" audit by Senate Finance Committee staff of directories from 12 different health plans last year showed an 18% success rate making an appointment with a mental health care provider.

• A third of 120 provider listings contacted by phone were inaccurate, non-working numbers or unreturned calls.
• A similar audit in New York State found 86% of providers were not in network, unreachable or not accepting patients.

In the lawsuit, a secret shopper audit of 100 providers in the directory performed by attorney Steve Cohen of New York-based law firm Pollock Cohen found only 7% of the doctors listed accepted the plaintiff's plan.

• Of those doctors, several were not accepting new patients or had an 18-month wait, he said.
• "This is just outrageous," Cohen said. "93% inaccuracy. It is just a lie."

Between the lines: Most commercial health insurance plans fall under the Employee Retirement Income Security Act of 1974, which has federal preemption and won't allow customers to sue under state consumer protection laws.

• The plaintiffs in this case, however, are not in an ERISA plan.

The other side: Anthem declined to comment on pending litigation.

What's ahead: The American Medical Association says part of a solution could be standardizing data submission so that medical practices aren't dealing with different submission processes for different plans.

• The Senate Finance panel, under Chairman Ron Wyden (D-Ore.), is looking at remedies. Lawmakers in the last Congress, for example, strengthened provider directory standards in Medicaid.