State Fines MH Insurers Over 'Phantom' Provider Networks

Two of Vermont's three behavioral health insurance providers have been fined by the state and a new law enacted to eliminate what experts call“ phantom networks” of clinicians who are supposed to be available to their subscribers. Psychiatrists and other mental health advocates urged better regulatory enforcement and passage of the new law, because inaccurate insurer lists complicate the already difficult task of finding mental health clinicians in a state with shortages of some providers.

Cigna and Magellan Health Services, which contract with Blue Cross and Blue Shield of Vermont, were fined $20,000 each by the Department of Banking, Insurance, Securities, and Health Care Administration (BISHCA) for providing customers with lists of clinicians, including psychiatrists, who are no longer practicing or not taking patients. Other psychiatrists listed included those who accepted the companies' insurance but were unavailable to care for the general public, such as the medical director of the state psychiatric hospital at Waterbury.

Francis Kalibat, M.D., a former president of the Vermont Psychiatric Association, joined leaders of other mental health professions in raising the issue to state regulators early in 2008 after a growing number of complaints from their patients.

“I thought what was going on was an outrage,” Kalibat said in an interview with Psychiatric News. “These people are paying for insurance that they then can not easily use because of this barrier to care.”

The BISHCA fines, levied in January, stemmed from violations of a Vermont law requiring health insurers to update every six months the list of physicians in their networks who are accepting patients or still practicing.

Cigna officials, when asked about the issue by Psychiatric News, issued a statement saying that the company aims to provide up-to-date and accurate information about available clinicians in their network.

“Health care professionals are contractually obligated to provide us with any changes to their information,” according to the Cigna statement. “We are working with [BISHCA] on a process that we believe will improve the accuracy of health care professional information.”

Magellan did not respond to requests for comment.

Patient advocates said dated provider lists that contain lots of inaccuracies further complicate the already difficult process of using managed care benefits for the first time, especially without an established relationship with a mental health clinician. One patient advocate group, the National Alliance on Mental Illness of Vermont (NAMI Vermont), has received many complaints from its members and the general public on the issue of inaccurate provider lists.

“When you are experiencing some psychological distress and feel like you really need to see a counselor, it can be frustrating to get a list like this and start making calls and be turned away and disconnected,” said Larry Lewack, executive director of NAMI Vermont, in an interview with Psychiatric News.

The problem also was investigated by state Rep. Michael Fisher, a Democrat, who pretended to be a patient looking for mental health care. Among the problems he encountered were that more than half of the listed physicians were no longer accepting patients. He supported legislation (S 114) that was passed in May 2008 that increased Vermont's regulatory authority over health insurers' provider lists to address patient complaints.

Other aspects of the new law direct regulators to examine whether utilization review deters “timely and appropriate care” and whether measures such as preauthorization reduce access to “medically necessary treatment.”

That legislation stemmed from the combined efforts of the various mental health professional groups and the major advocacy organizations in the state, said David Fassler, M.D., legislative representative of the VPA and APA secretary-treasurer.

“Working together, we've been able to pass legislation designed to promote access and to enhance the state's regulatory authority with respect to issues such as delayed payment, inadequate or 'phantom' networks, and excessive utilization review and preauthorization requirements,” Fassler said.

Since enactment of the law, insurers have worked with state regulators to update their provider lists. For instance, no longer will insurance companies be allowed to count unreturned phone calls from clinicians as sufficient reason to keep them on the company's list of available providers. Regulators now require direct contact with clinicians to keep them on the list, Christine Oliver, deputy commissioner of BISHCA, told Psychiatric News.

The inaccurate lists existed in a state that generally has a good number of some types of mental health clinicians. Representatives from Magellan reported to state legislators in 2008 that Vermont has a “huge number” of mental health clinicians, with only two areas of the state experiencing a shortage. That contention is generally supported by available data, such as a 2008 study published in Psychiatric Services that showed that Vermont's concentration of advanced-practice psychiatric nurses is more than three times the national average.

Lewack, of NAMI Vermont, agreed that there are high numbers of some types of mental health clinicians but emphasized that shortages exist for other clinicians, such as child and adolescent psychiatrists.

General psychiatrists also are in short supply in the state, Kalibat said. He described the fines as “a long-overdue first step.”

“[Patients] are drawing from a restricted pool,” explained Kalibat. “And then their access to people in that restricted pool is further restricted because they may have to go through 10 names to find one who is viable.”

The new behavioral health insurer regulatory law is posted at<www.leg.state.vt.us/database/status/summary.cfm?Bill=S%2E0114&Session=2008>.▪