Unverified selections can lead to exorbitant out of network charges
Employee benefits and ERISA attorney J.J. Conway of Michigan-based J.J. Conway Law is urging employees switching health insurance companies during open enrollment season to double check that providers listed in the health plan’s provider directory are current and accurate. Conway says so-called ghost networks may give employees a false sese of security that the providers they see in the directory can meet their needs.
“Because health insurance plans are covered by federal ERISA protections, the practice of including providers in the directory who are only accessible with caveats – or have left the health plan altogether- is an ERISA violation,” Conway said. “Employee benefits are legal contracts between an employer and an employee and employers have an obligation under ERISA to ensure that their health plan information – including provider networks - is timely and accurate.”
Conway lists the most common problems with ghost networks:
• Providers erroneously listed as plan participants – sometimes years after they exit a health plan
• Providers listed who have retired or died
• Providers not accepting new patients
• Providers with limited services not noted in the directory, such as a listed psychiatrist that excludes children’s mental health services
Conway has represented clients forced out of their network – and sometimes even out of state – to find providers for their children with eating disorders and other life-threatening mental health conditions.
“I have seen clients rack up $750,000 in medical bills to secure out-of-state mental health treatment for medically vulnerable teens,” Conway said. “It’s not unusual in these cases for the insured to have thought they had specific services covered because they saw provider listings in their health plan directories. This is a clear example of the financial and mental/physical devastation that can be wrought by ghost networks.”
Conway notes that a crackdown on ghost directories is finally emerging. In an Illinois lawsuit, one health plan is being charged under the Racketeer Influenced and Corrupt Organizations (RICO) Act, a federal law typically identified with criminal organizations that provides criminal penalties and a civil cause of action.
If you are signing up for a new health insurance plan this open enrollment, don’t trust the online directory. Conway urges employees to call listed providers to ensure they are still active providers in the plan.
“Because health insurance plans are covered by federal ERISA protections, the practice of including providers in the directory who are only accessible with caveats – or have left the health plan altogether- is an ERISA violation,” Conway said. “Employee benefits are legal contracts between an employer and an employee and employers have an obligation under ERISA to ensure that their health plan information – including provider networks - is timely and accurate.”
Conway lists the most common problems with ghost networks:
• Providers erroneously listed as plan participants – sometimes years after they exit a health plan
• Providers listed who have retired or died
• Providers not accepting new patients
• Providers with limited services not noted in the directory, such as a listed psychiatrist that excludes children’s mental health services
Conway has represented clients forced out of their network – and sometimes even out of state – to find providers for their children with eating disorders and other life-threatening mental health conditions.
“I have seen clients rack up $750,000 in medical bills to secure out-of-state mental health treatment for medically vulnerable teens,” Conway said. “It’s not unusual in these cases for the insured to have thought they had specific services covered because they saw provider listings in their health plan directories. This is a clear example of the financial and mental/physical devastation that can be wrought by ghost networks.”
Conway notes that a crackdown on ghost directories is finally emerging. In an Illinois lawsuit, one health plan is being charged under the Racketeer Influenced and Corrupt Organizations (RICO) Act, a federal law typically identified with criminal organizations that provides criminal penalties and a civil cause of action.
If you are signing up for a new health insurance plan this open enrollment, don’t trust the online directory. Conway urges employees to call listed providers to ensure they are still active providers in the plan.
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