When I started my training in psychiatry, a senior doctor told me I should have a therapist of my own. He explained that it’s essential to understand myself so I can better understand my patients.

That made sense, so 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.

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In a recent study, 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.

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.

Maybe insurance companies don’t know their lists are inaccurate. Maybe they do but choose not to do anything about it. A more alarming possibility is that some companies intentionally keep the lists inaccurate to save money by preventing access to mental health care. After all, ghost networks benefit insurance companies: If it’s hard to find a provider who takes your insurance, it’s less likely you will access services that the insurer will have to pay for.

That concern may be founded, given other recently revealed strategies used by insurance companies to avoid paying for mental health. As Massachusetts state Sen. Cindy Friedman, who has been working to get insurance companies to improve their provider lists, told me, “They’ve known about this for a long time and they haven’t done anything about it. It’s difficult not to assume that this kind of barrier is intentional.”

No matter the reason, ghost networks are unacceptable.

Imagine realizing (or acknowledging) that you have depression — a defining feature of which is loss of motivation — and start looking for a psychiatrist. After calling a McDonald’s, a jewelry store, and providers who say they don’t take your insurance but will be happy to see you for $250 per hour that you must pay out of pocket, you’ll likely be inclined to give up.

Ghost networks are particularly disturbing when it comes to Medicaid plans. States provide insurance companies with contracts to create plans for their poorest citizens. Though many of these companies are nonprofits, they often contract with for-profit companies to administer the mental health benefits. By failing to maintain accurate provider lists, these companies profit from taxpayer dollars while the most vulnerable mental health patients can’t find the care they need.

The outcomes have the potential to be devastating: an individual with severe depression who dies from suicide before he finds treatment, or someone with paranoid psychosis hurting herself because she never received access to effective medication.

Friedman told me a story about a Massachusetts parent who struggled to find an in-network psychiatrist for her son who was hearing voices. Despite calling countless psychiatrists who supposedly took her insurance, she was unable to find one. One day before the 19-year-old got help, the police were called to the home because he locked himself in his room and was yelling. He struck a police office and was arrested.

Insurance companies are finally getting called on the carpet about ghost networks. In California, regulators fined two insurance companies for overstating the breadth of their Obamacare networks in all specialties, not just psychiatry. A 2016 California law now requires Medi-Cal plans to update their online provider directories weekly. Aetna recently settled with the state of Massachusetts after its attorney general launched an investigation into the company’s inaccurate network lists. Massachusetts legislators have introduced “An Act to Increase Consumer Transparency about Provider Networks” that would require insurers to keep updated and accurate lists of in-network providers.

State-level progress is good, but this issue deserves national attention since it affects people across the country in all sociodemographic categories. It also should apply to both private and government-sponsored insurance plans.

Without access to appropriate mental health care, vulnerable people across the U.S. will continue to suffer, and some will die. Every insurance company should be required to keep its provider lists updated so they can’t collect premiums for services they don’t actually provide. Insurers should not profit because they have failed to make mental health care accessible.

Jack Turban, M.D., is a resident physician in psychiatry at Massachusetts General Hospital.

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  • This article artfully ignores the elephant in the room. What about the psychiatrists? Not to defend insurance companies, but how do insurance companies create a network of psychiatrists when it is nearly impossible to find psychiatrists that accept insurance?

  • I’m a Clinical Psychologist in NYC and I’ve experienced this frustration for years. Excellent that California and MA are taking control of this, because here in NY, it is rampant and no attempts I know of are being made to curtail it. I routinely give this advice: call your insurer, tell them you can’t locate the type of provider you are looking for, and that you do not want them to send you a list of providers from the web site, because you’ve called multiple providers already without success. You want them to help you find the provider you need. Insurers have services that reach out to providers and they do the search for you. I know that in NYS the service is called Compass for Empire BCBS, and another service insurers use is called Health Advocates. The insurance companies don’t advertise this, of course, but it exists. You simply have to be resolute with your insurer and tell them that you want them to find you X type of provider, because you’ve called multiple providers on the list, can’t find one on your own preventing you from using the benefits you are paying for (or have paid for as in the case of Medicare). I have heard from numerous clients that this procedure has worked for them and I hope it works for one of the readers of this post.
    An issue I haven’t seen raised here has to do with providers themselves. I have been told by clients that they called providers who are on the lists and who are using them as marketing tools to sell the client out of network services. Some say they “participate” with the network, meaning they are out of network, and then explain the out of network process. Some say they no longer are in network but will offer “sliding scale” fees. Recently I heard of a provider who was on an insurer web site in NYC but had relocated to Florida and she was selling out of network teletherapy! Personally, when I left an insurer a while back they did not remove my name from the list for weeks. Since I refuse to be part of this practice, I called (and called) and faxed (and faxed) until they removed my name. It is also up to us to not participate in these ghost networks.
    Lisa Salvato, Ph.D.

  • Have had the same experience. So it’s not just because I live in a rural area…I don’t want to drive all the way into Nashville where traffic and parking is anxiety producing, but I’ll go up to Bowling Green KY where my insurance is in network…except I can’t get in to see anyone there either. PCP’s have been treating me for several years but simply don’t have enough education in behavioral health to find the right meds that will help. There are non profit clinics around that take Pt’s with Medicaid and Medicare that are unpleasant. At this point in my life, I’d like to be able to go to a clean, quiet office that isn’t an hour a way in a heavy traffic urban setting. So incredibly frustrating.

  • These comments are an ongoing testament to the tragedy that is the modern day mental health infrastructure. As someone with more than four decades of experience in it, in state hospitals, University hospitals, large inner cities, and suburban private practice, I know from first hand experience how desperate the situation has become.

    The insurance industry has made very specific choices to damage the system. And that includes both private carriers and Medicare and Medicaid, which is the federal government. There are three things that are at the core of the problem. All of them could be changed with a stroke of the pen.

    First is the level of reimbursement for providers. The average level of reimbursement for psychotherapy is in the range of 50% of the cost of a lawn mower tuneup. That is completely out of proportion to the overall marketplace of labor. Obviously that level of reimbursement does not lure talented people into the field. It does not compensate for the education level, skill level, emotional demands, and administrative demands. If society is remotely serious about establishing and maintaining a highly skilled workforce in the mental health world, those numbers have to change.

    Second is the issue of the co-pay and deductibles. This is an extremely complicated knot to untangle. Some people simply have no further money to contribute, some do. There has to be some kind of plan which will call upon patients, providers, and the insurance industry to make more effective use of the resources in all of those areas. Having well-to-do patients contribute more to their care, in some cases, is appropriate. Likewise, having society help with severe chronic psychosis over a lifetime is also something that is in the best interest of the overall public health. This part of the picture is too complicated to fully describe here.

    The third and last piece of the puzzle is the in-network/out-of-network nightmare. This is a scheme completely under the control of the industry, which is only aimed at decreasing costs for the industry. It does this in all of the ways documented in the painful comments on this string. This structure could be done away with instantly. The insurance industry could be forced to pay “any licensed provider”, all at the same rate. The industry would completely throw a fit at any proposition of this, because it will cost them money. But it is, without a doubt, the first and easiest change that could be made.

  • Right on the mark! Live in a town of over 3 million people and have not located even one psychiatrist that I can travel to , that accepts insurance. Over and over, I’m told ” Number no longer in service, moved, not in practice any longer, deceased, no openings , you have too many problems”, and of course the familiar,” no don’t accept your insurance”.
    Yes, medicare will willingly provide their own lists. I’ve never got hold of any
    person on any list from medicare…all moved, dead, or not in practice. No joke.

    This goes the same for psychologists, which was my primary target. To emphasize the problem, I’ve seen 35+ and not one of them were even close to
    helpful. I’ve had my personal info compromised, appts. cancelled, been made to wait far too long, with an appt. , told that there was no hope for me. I’d never get better, phone calls/emails not returned ( this is rampant ) and so many that outright lied when questioned if dealt with specific issues. I’ve been told get a book , read it, do what it says, and it just goes on and on. Naturally, none of them lasted. Who would continue with that sort of ‘treatment’?? Now, I’ve gone thru all those who do accept the ins., which obviously are not the cream of the crop. Left on my own. Literally. I totally understand why some folks elect for suicide. I can see how a
    person can and is pushed over the edge. With that ‘sort of care and concern’. wouldn’t most, if it’s left to go on far too long?? I’m too stubborn to give up, but I have given up on finding any assistance. It is NOT available.

    Why has this been allowed to continue? Would those in power to change it allow their parents, siblings, children, friends , co-workers and neighbors to be treated this way? I think not. Then WHY is it ok for the rest of us????????

  • What about Medicare? Medicare should maintain a list of mental health providers in each state, but it doesn’t. People don’t even know that Medicare covers 80% of psychotherapy!

  • Thank you for your insightful message about the reality of the psychiatric situation regarding the necessity for one’s own mental health practitioner’s own experiences as a patient too. Also the accuracy of this seemingly ongoing situation with health insurance companies who intentionally try to block patients in need, from trying to access their own providers’ disingenuous attitudes of the way they actually prevent those most needed to find the professional health care from credible and ethical psychiatrists, psychologists, and the several other practitioners who are highly qualified for their health care knowledge and ethics to treat their patients with a great benefit to help patients who are amongst those who require treatment for their mental and emotional health care.

    When I received my several degrees years ago I already had been in therapy with my psychiatrist for years. Our approach to the treatment protocols advanced as I became more than not, a psychotherapist in private practice. I was still doing my own inner work with my own issues with my three different psychiatrist, psychologist, and the continued supervision of more than what was required to remain in my professional life as a therapist who had also ancillary degrees and personal training in my field of my expertise, always keeping the protocol for attending conferences and workshops each year, which was a great experience for me as it was for my colleagues too.

    I especially felt strongly that the practitioner had to have access to one’s own mental health care treatment for themselves too. I would speak to this each moment I could, because we know that it is something that is indeed helpful for all, that our own professional practitioners were doing their own inner work too!

    When I first started my own private practice, after being employed by some of the most well known practitioners in our field, I finally had the opportunity for my own practice that I was very satisfied and passionate about for the years of my private practice experience in one phenomenal state where I lived longer than the other seven states for my entire professional life; that was especially difficult for me to find in a few of the states where I resided throughout the USA.

    However as I did in the Philadelphia area, I always vetted a psychiatrist or two with my patients seeing them for medications and for explicit cases that I personally and professionally recognized those patients who actually required the specific treatment that I did not have, because the differences that exist in the professional health care issues that are most beneficial with a psychiatrist, rather than only seeing a therapist who did not have the same type of training that we did not have in our demanding professional training which Psychiatrist’s receive that we did not.

    Also I never accepted insurance companies and instead back in the day, would provide my patients with everything they needed for reimbursement from their insurance companies. I also had a sliding fee scale for the people who could not afford to purchase insurance for their treatment. Additionally, I would see one individual, one couple and one family pro bono as my own personal life experiences to be available to those of patients in need but could not afford the sessions that they were in need of being helped by practitioners who do not have a sliding fee scale, nor a pro bono system.

    I wanted to do something for some individuals who really needed this care to navigate their journeys to self realization about the plethora to recognize the aspects of themselves who they seldom knew existed in all living patients and the connections that they would benefit from their recognition of their own sense of Self, seen in more than not individuals who are committed to the process of their own, to grow into the self they didn’t know existed.

    Finally, I am somewhat disturbed by the app’s as therapist in this manner. I am not familiar enough to adequately evaluate the new therapy treatment with apps for the absent therapists. It’s something that I want to know much more about, before I am ready to write about this relatively new methodology into the human condition via an app. But I admit that I am not as happy with this app for patients who have been working with there therapists, for a while. The whole concept is something that I must learn more about, before I endorse, or disagree with this new app.

    It is after all, part of the necessity for my own development of gaining experience about something that I admit to not typically thinking that this has the merits of which it states it has.

    Thank you for your interesting article about this topic that I would like to keep informed by the outcome data that will require some time yet to make that it well informed individual who has data for the purposes of gaining the results from a significant number of subjects in a trial that is a scientific research outcome of the complexities of the human condition.

    Respectfully,
    Catherine M. Dunn

  • Not true, Mary. I am a therapist, and I have asked other therapists, and none of us have solid connections with psychiatrists who have openings, are good, and return calls! It’s heartbreaking that access cannot be had even with therapists advocating.

  • Most psychiatrists do not do therapy so I am wondering did you go to an old time psychoanalyst or did the psychiatrist refer you to a Clinical Psychologist or LISW?
    What your mentor should have suggested you do is volunteer at a homeless shelter or food pantry with observing various 12 steps groups and oh my – maybe a Hearing Voices group. Another aspect of education and self support would be to do some Music Therapy or Art Therapy.
    Maybe some EDMR therapy if you have had trauma in your life and if you are in the field , I can guarantee you have some type of bones in the closet.
    Again, this is old old news. This was talked about in my Department of Psychiatry staff meetings in the 1980’s it has only exponentially gotten worse between bad technology and greed and malfesence in the medical/ insurance complex.
    Actually, the only reason to seek psychiatric support these days is for biopsychistry unless you want or need an old school psychoanalyst.
    Otherwise just look up Clinical Psychologists and LISWs.
    They have course have their own problems these days. Your mentor gave you old timer and current bad advice.
    All therapists these days have a direct line to a psychiatrist and that for the past thirty years is always the fastest way to be seen.
    But kudus for the wonderful examples of current day total incompetence for all those involved in the so called helping and support professions.

    • Mary, your comments do not answer my experiences over the years. I do agree that the problem is not new, and is getting MUCH worse. I’m adventurous in terms of therapeutic approaches, but I still want an experienced psychiatrist as well. I have been to “hearing voices” groups and appreciate the recovery model, but I dont hear voices. Many of the other therapies you mention are either equally hard to find in many areas or not effective (EMDR), in my experience.
      I do agree that good licensed therapists are worth more than gold, but they’ve never gotten me anywhere with a psychiatrist, other than names and numbers to try.

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