US patients sue over insurance ghost networks

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nbcnews.com

Attorney Sara Haviva Mark.NBC News nbcnews.com

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Calderon and her partner, Chris Russell, embrace at home in their kitchen.NBC News nbcnews.com

Calderon sits with her partner, Chris Russell, and their daughter at dinner.NBC News nbcnews.com

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Patients who try to use their health insurer’s online directory to find an in-network doctor are increasingly discovering that the network exists mostly on paper. NBC News reports that “ghost networks”—provider lists filled with wrong numbers, outdated addresses, clinicians not taking new patients, or providers who do not actually accept the plan—are now the subject of a new class-action lawsuit.

The case was filed in December by New York City government workers against EmblemHealth, alleging the insurer’s directory misrepresented access to mental health care. The plaintiffs say they spent hours searching and calling only to find providers were out of network or unavailable. One plaintiff, a special education teacher, said she sought help after a miscarriage and suicidal thoughts but could not find an in-network clinician who could see her.

The lawsuit targets a gap between what regulators require and what patients experience. Insurers can market lower premiums if the effective network is narrow, because fewer in-network appointments means fewer claims paid at contracted rates. A directory that looks broad can still function as a barrier if the listed clinicians are unreachable or not accepting patients. The cost does not disappear; it shifts into patient time, delayed care, and out-of-pocket payments when people give up and go outside the network.

Enforcement has been weak. NBC notes that state regulators can fine insurers for inaccurate directories, but rarely do. At the same time, a federal law—the Employee Retirement Income Security Act of 1974 (ERISA)—limits many patients’ ability to sue insurers under state consumer-protection rules when their coverage is employer-sponsored.

The new lawsuit attempts a workaround: government employer health plans are not subject to ERISA in the same way, allowing plaintiffs to bring claims under state law. The American Psychiatric Association is also a plaintiff, arguing the alleged misrepresentation amounts to false advertising about what psychiatric coverage is actually available.

EmblemHealth declined to comment on pending litigation, according to NBC. The case’s premise is straightforward: if “network adequacy” is measured by the size of a spreadsheet rather than by whether a patient can book an appointment, then compliance becomes a documentation exercise—and access becomes a scavenger hunt.

The directory may show dozens of options. The phone calls still end in voicemail.