Many folks looking for a therapist or psychiatrist flip to the record of in-network suppliers provided by their insurance coverage plan. But typically, most of the medical doctors on the record don’t take that insurance coverage plan, aren’t accepting new sufferers, or just don’t reply the telephone. Researchers and journalists name this phenomenon a “ghost network.”
So, who you gonna name if you encounter a ghost community? A ghostbuster.
That’s the place Abigail Burman is available in. Burman is a lawyer who has studied ghost networks and volunteers her “ghostbusting” providers to assist folks in her life navigate these networks and acquire care.
In this episode of “An Arm and a Leg,” host Dan Weissmann speaks with Burman about what it took to get her good friend the care she wanted and what steps you possibly can take to get insurance coverage to pay for remedy.
Dan Weissmann
Host and producer of “An Arm and a Leg.” Previously, Dan was a employees reporter for Marketplace and Chicago’s WBEZ. His work additionally seems on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.
Credits
Emily Pisacreta
Producer
Adam Raymonda
Audio Wizard
Afi Yellow-Duke
Editor
Click to open the Transcript
Transcript: Mental Health ‘Ghost Networks’ — And a Ghostbuster
Note: “An Arm and a Leg” makes use of speech-recognition software program to generate transcripts, which can include errors. Please use the transcript as a device however examine the corresponding audio earlier than quoting the podcast.
Dan: Hey there–
So, one subject we now have NOT addressed on this present till now has been psychological well being. And it’s not as a result of it isn’t essential, proper?
Just ask anyone who’s lived by means of a multi-year international pandemic.
And it’s not like ACCESS to psychological well being care — determining tips on how to pay for it, or tips on how to get insurance coverage to pay for it — isn’t an issue.
Actually, just about the other. It’s perhaps the most important drawback. It’s simply notoriously horrible.
We haven’t gone there as a result of, nicely, primary: The horror tales are infinite.
And two, I’ve had completely nothing to supply, when it comes to what are we gonna do about it. Until now. Because now I’ve met someone who has really received a battle on this terrible area…
Abigail Burman: my identify is Abigail Burman and I’m an legal professional specializing in shopper safety healthcare and know-how.
Dan: Abigail’s additionally a coverage skilled on a few of these issues And she’s develop into a problem-solver for folks in her life.
Abigail Burman: It’s develop into somewhat little bit of my superpower to only assist associates discover an in-network therapist or in-network psychiatrist.
Dan: Or, if there’s principally no such factor, to get their insurance coverage to pay for an out-of-network supplier.
She despatched me a guidelines she’d posted to a web based discussion board, with the title, “A broad guide to getting therapy/psych appointments covered when you can’t find anyone in network”
It’s primarily based on steps Abigail took on behalf of a good friend just lately, and it’s terrific.
It combines the same old unreasonable quantity of persistence and grit, and time that not all people has– and provides some key authorized data.
Now, this authorized key received’t open each door, in fact. It’s form — and whether or not it’ll work in any respect for you– is determined by the place you get your insurance coverage, and on the place you reside.
In truth, even with that authorized data on her facet, the steps in Abigail’s guidelines aren’t precisely what labored for Abigail on this case. It took extra.
Again, greater than is cheap. More than most of us have in us, frankly.
But we’ll share what did work — as a result of there ARE insights right here that even us non-superheroes can positively use :
And past the mechanics, the precise suggestions, I discover Abigail’s strategy — the spirit through which she suggests we apply ourselves to those issues– for ourselves or for others —actually refreshing.
This is An Arm and a Leg, a present about why well being care prices so freaking a lot, and what we are able to perhaps do about it. I’m Dan Weissmann, I’m a reporter, and I like a challen.ge.
So our job on this present is to take some of the enraging, terrifying, miserable elements of American life — and infrequently has that phrase “depressing” carried extra weight than on this story about psychological well being– and produce you one thing entertaining, empowering and helpful.
Abigail’s private super-powers develop out of her coverage analysis.
Abigail Burman: So as with all good tutorial work, it began with a grudge. This is my tremendous villain origin story.
Dan: It began throughout her first semester in legislation faculty, when she made an essential discovery.
Abigail Burman: legislation faculty is uh, a poisonous stress cooker, and so I, like loads of my classmates realized halfway by means of that speaking to somebody could be a good suggestion.
Dan: So she seemed up the therapists in her insurance coverage firm’s listing.
Abigail Burman: I referred to as most likely 20 medical doctors and didn’t hear again from anybody. I really ended up seeing somebody out of community.
Dan: And she bought mad. And she determined: I’m gonna discover out what the hell is happening right here. So she spent just about the remainder of legislation faculty researching precisely that.
And her analysis confirmed her: This factor she’d skilled? It was a recognized factor. It had a reputation.
Researchers and journalists referred to as it a “ghost network.”
A “ghost network” is the place your insurance coverage firm says to you: You want a therapist? Oh certain. Here’s a listing of therapists who take our insurance coverage– our “network directory.”
And perhaps you name just a few. Maybe you name twenty, like Abigail. Maybe you name 73, which is what one lady did, based on a current Washington Post story. Yep. 73.
And they are saying, “What? No, we don’t take that insurance.” Or, “We’re not taking new clients.” Or no person even solutions the telephone as a result of it’s been disconnected for a very long time.
And the issue isn’t that you simply’re having unhealthy luck. The drawback is: The community itself — all these suppliers supposedly ready to take your name and take your insurance coverage — is a ghost, a illusion.
Of course, operating right into a ghost community can conjure up all the sentiments of being ghosted.
Abigail Burman: That may be so isolating if you simply suppose it is a private annoyance somewhat than with the ability to identify it as a much bigger drawback with your entire system.
Dan: I imply, it could actually additionally really feel like, it could actually really feel like a private failure, proper? Like, oh, an actual grownup might do that.
Abigail Burman: Exactly. If I simply organized my life higher, if I simply tried tougher, this might be higher.
Dan: But Abigail’s analysis confirmed her: This is just not a private failing. A examine of networks in only one metropolis, Washington, DC, discovered that solely half of the telephone numbers listed even labored in any respect.
And Abigail’s on a regular basis expertise confirmed her: Those findings in Washington, DC, weren’t figuring out an remoted bother spot
.
Abigail Burman: I noticed I used to be onto one thing after I would inform folks about this and everybody has a narrative.
Dan: So she let her rage gasoline years of educational work. She revealed some findings in a protracted article for the Yale Law and Policy Review referred to as Laying Ghost Networks to Rest.
The paper paperwork the issue’s scale — spoiler alert, it’s REALLY large, and never restricted to psychological well being — and lays out coverage prescriptions for combating them.
Meanwhile, Abigail has graduated from legislation faculty, and moved to DC. Now it’s late 2022. Abigail’s good friend wants a therapist, and he or she’s like…
Abigail Burman: Put me in. I’m prepared.
Dan: This begins with Abigail’s good friend attempting issues the “normal” method:
Abigail Burman: They referred to as like 10 or so and simply aren’t getting any hits both persons are not really taking new sufferers or they simply usually are not replying. I feel we bought one or two unsuitable numbers.
Dan: Again, regular. And not a step you possibly can skip. Going up towards this drawback — and documenting it — is what offers you standing to inform the insurance coverage firm to resolve it for you.
Abigail Burman: They had managed to get by means of to 1 supplier, however they stored saying that their earliest appointment could be in 4 months, which is unacceptable And so that is the place I got here in.
Dan: It’s unacceptable morally. It’s unacceptable as a remedy plan. And as a result of Abigail has studied the legislation right here, she is aware of it’s unacceptable legally. At least in some conditions. Including her good friend’s.
Abigail Burman: Affordable Care Act, market plans, Medicaid plans, and Medicare plans are all topic to guidelines round community adequacy.
Dan: Network adequacy: If you’re gonna take away one authorized time period from this episode that’s the large one: Network adequacy. Are there sufficient medical doctors in your community to truly present care?
That’s the bedrock for every thing else right here.
Abigail Burman: Let’s say you could have like a 500 particular person listing, two of them will really decide up in case you name, however discovering them requires the opposite 498. That’s not what you’re entitled to. That is just not an enough community. The key with all of those guidelines and rules is that, um, it’s meant to make searching for care not a burden.
That if you end up already in a spot of misery, it needs to be fairly straightforward so that you can attain out and get assist. And I feel that must be your guidepost. Think about what it’s cheap to count on of somebody in your scenario.
Dan: So, in case you’ve referred to as, say, ten numbers and are arising empty, you’ve bought fairly good proof that the reply is… what’s being anticipated of you isn’t cheap.
You’re gonna be telling the insurance coverage firm: If you’ve bought an enough community, show it.
Abigail Burman: Your stance at that time that you simply wanna maintain agency in is, I’ve referred to as medical doctors. I’ve completed my job, I’ve spent this many hours.
Thank you. But no, I can’t be doing that anymore. Now the burdens shift to you.
Dan: In different phrases, in case your community actually is enough, you’ve gotta discover me someone in it. Or pay for me to go outdoors of it.
And I’ve gotta acknowledge right here: As bedrock goes, it’s … fragmented. And incomplete. For starters, each state makes its personal guidelines for community adequacy.
And inside a given state, the foundations are totally different for these three totally different sorts of plans: Obamacare plans, Medicaid, and Medicare.
And for lots of us who get insurance coverage from work… we’d be a complete totally different authorized construction.
But past the authorized specifics the fundamental thought is: Somewhere, by some means, you’ve bought a proper to precise care from someone who takes your insurance coverage.
Insurance is a contract. They’re getting one thing — cash — and also you’re imagined to get one thing: Access to care from someone for in-network charges.
Abigail Burman: Either you or another person is paying so that you can get this service out of your insurer. This is what that cash is meant to cowl. And in case you can’t get that, somebody’s simply getting cash totally free.
Dan: So, I’m simply gonna observe a few Abigail’s broad tips right here, and we’ll submit a hyperlink to her full guidelines wherever you’re listening to this.
And we’ll complement it with a few of what Abigail instructed me after we talked. For now, the gist is:
Her record begins with authorized phrases like “network adequacy” that you may mix in a Google search– together with the identify of your state– to see how they apply to your scenario.
And it ends with some common goal recommendation like, quote “The key is to be a giant asshole.” Unquote.
Abigail Burman: I don’t imply, , screaming at folks utilizing swear phrases, et cetera, however it could actually really feel like you’re being a jerk in case you stand your floor and say no. But it’s value it. And if nothing else, simply do not forget that. Like you’re by no means gonna speak to any of those folks once more.Probably.
So, worse involves worse, in case you get too stressed, you possibly can grasp up and name once more.
Dan: In different phrases, the important thing isn’t to BE an asshole. It’s to tolerate FEELING such as you’re being an asshole.
But what you’re doing is letting the opposite particular person know: You know your precise rights.
I inform Abigail, it jogs my memory of how Jacqueline Fox– a legislation professor who used to do this type of problem-solving as an legal professional — put it: You need the particular person on the opposite facet to get the sensation, “There’s a grown-up here who seems to be getting annoyed.”
Abigail Burman: Exactly. I feel that’s the, the precise vibe you need is type of, um, I’m disenchanted, not offended. And I, that’s how I attempt to enter these is form of like, right here is the rule, here’s what you could have completed. I merely don’t perceive why you possibly can’t adjust to the legislation. Um, additionally like to you, you all the time wanna put a selected request on the finish.
Uh, say precisely what you need, um, simply so it’s actually clear. Uh, and ideally, , say, I, I count on to answer again by this time, simply so there’s one thing preserving the dialog shifting. If you don’t get a response, you possibly can then observe up and say, I believed, , I’d ask for a reply by then. Where, the place is my reply?
Um, and so, yeah, that’s type of the, the final construction you wanna absorb these interactions is like, I’ve seen that. Like, I do know that is what I’m entitled to. This is what occurred. How are we, collectively working collectively, going to repair this?
Dan: Coming up in a minute: What occurred when Abigail really went into battle for her good friend.
(Midroll)
This episode of An Arm and a Leg is produced in partnership with KFF Health News. That’s a nonprofit newsroom protecting well being care in America., Their work wins all types of journalism awards yearly, and I’m honored to work with them.
So, Abigail’s good friend had referred to as a bunch of therapists that had been imagined to be lined by their insurance coverage– discovered bupkis. Abigail steps in.
Her good friend occurs to be on Medicaid, which is type of a best-case situation for this form of factor: Not solely is Medicaid regulated by states, there are typically detailed guidelines — contractual language even — about issues like community adequacy.
Abigail seemed up the precise regs that utilized in her good friend’s case, stored them readily available, and began in with the telephone calling.
If you’ve been listening for some time, or in case you’ve completed one thing like this, a few of what occurred will likely be acquainted.
Once the primary few calls didn’t get wherever, Abigail began working her method up.
Abigail Burman: The language that’s typically used is you wanna ask to have your criticism or your grievance escalated. You need it to go to somebody who perhaps has somewhat extra energy, little extra expertise.
Dan: She thinks it took perhaps 5 calls to get to anyone on the insurance coverage firm whose response went past, “Huh? Whatever. Sucks to be you.”
Abigail Burman: I lastly bought a girl who was like, yeah, that is unhealthy. What you need is what we name an administrative grievance. She stated, okay, I’m going to with you on the telephone. I’m gonna name two or three medical doctors and see if they’ve an appointment. If not, we are going to file an administrative grievance.
Dan: The lady dialed just a few medical doctors whereas Abigail was on the telephone, bought nowhere, and filed an administrative grievance.
Which, , nice. But that’s not a health care provider’s appointment. File it underneath Abigail’s common recommendation of: Do every thing. Go on document in all places. And hold going.
Next, Abigail stored calling, stored asking to speak with somebody on the insurance coverage firm with extra juice. Someone who might really authorize paying for an appointment with an out-of-network doc, since there weren’t in-network docs.
And after one other like full day on the telephone, she bought to that somebody.
Abigail made her particular request: I would like you to authorize fee for out-of-network supplier, because the rules require. And…
Abigail Burman: They say we now have no course of for this. This doesn’t exist.
Dan: Like, this factor that the legislation says they need to do– get you a supplier and lower a examine — this particular person’s saying they don’t have any course of for it.
Abigail Burman: I learn them the regulation over the telephone. It didn’t, didn’t change their place.
Dan: I’d’ve actually struggled in that dialog to include my rage. I imply, it’s simply flabbergasting, proper? Like, I spent all day getting on the telephone. I imply, all of this jogs my memory of the Wizard of Oz, they usually had been like, nobody can see Oz.
And , she’s, she’s like, I’m going to see him. And, after which she sees him and he’s like, go away and are available again tomorrow. . I’m Oz.
Abigail Burman: precisely. It is a, it’s a full runaround. Um, and so if you get to this place, I feel it’s important to let the fad gasoline you, perhaps take a break, eat some snacks.
Dan: And hold going with different methods. Including ones which will appear fairly out of the best way at first.
So Abigail referred to as the workplace of her good friend’s state consultant.
And of all the teachings from Abigail’s story, this one could be the MOST essential.
Abigail Burman: This is the key trick for any interplay you’re having, largely with authorities businesses, but additionally typically with personal corporations. Um, your entire elected representatives from native by means of to Congress, they’ve staffers whose solely job it’s, is to make your interactions with these techniques simpler.
Dan: Abigail really labored for a member of Congress as soon as upon a time, so she’s seen this all from the opposite facet.
Abigail Burman: Your elected representatives, have huge sources at their disposal. And the great ones know that the best way you get reelected is by serving to folks with their particular issues and can go outta their strategy to do it.
Dan: You don’t need to be a former Congressional aide your self to name your state consultant’s workplace. I imply, generally, a state rep doesn’t even have THAT many constituents. But they do have employees.
So, Abigail didn’t name the state rep’s workplace as a result of she knew somebody there. She referred to as as a result of she knew what somebody there might DO.
And now it too.
Abigail Burman: These staffers have secret telephone numbers, they’ve electronic mail addresses, they get issues mounted.
Dan: A staffer had given Abigail a direct electronic mail to the fitting particular person on the state regulator’s workplace–.
Abigail Burman: And so we emailed them, bought a reply again virtually instantly saying, yeah, you’re proper, that is unhealthy.
Dan: And then she heard from someone ELSE altogether.
Abigail Burman: I feel inside an hour or two, uh, bought a telephone name from the healthcare plans lobbyists for the state, saying that, yeah, she was personally going to repair this, promising an appointment throughout the subsequent two days.
Dan: Holy shit. I imply I really like that it’s the lobbyist
Abigail Burman: Yeah, that was particular.
Dan: I imply, it’s very fascinating, proper? That just like the official channels didn’t go wherever. That what occurred was the political actor bought concerned and a political actor on the insurance coverage facet got here and made it occur.
Abigail Burman: Exactly. The key’s you simply, it’s important to hold shifting up and it’s important to press on all of the levers that you may.
Dan: In this case, as a result of Abigail’s good friend was on Medicaid, the state was really paying the insurance coverage firm immediately, so getting them concerned was most likely a more practical lever than in different conditions. But it labored!
Something really labored.
And making that occur took an unbelievable quantity of labor, quantity of sources. That is among the BIG take-aways right here, and it’s not precisely a cheerful one.
Abigail estimates she put like half a workweek into this. [I mean, holy crap.]
Abigail Burman: I used to be fortunate sufficient to be in a job the place I, I might, , my boss was understanding I may very well be taking these calls on the workplace for typically hours at a time.
Dan: And she’s fluent in English. And she’s snug navigating forms, to say the least.
Abigail Burman: I’m a lawyer who labored in healthcare coverage earlier than legislation faculty, and I do that work professionally, and it nonetheless took me so lengthy. And that was with the added privilege of, getting taken significantly due to my training, as a result of I’m white, due to all this stuff.
Dan: I imply, all of those benefits are among the many causes Abigail’s agency expenses a whole lot of {dollars} an hour for her time.
So the sources it took to get this particular person win are, on that scale, staggering. It completely blows.
And but: The a part of Abigail’s story that stands out essentially the most to me– past the precise suggestions, and past the outrage– is an concept that we’ve began speaking somewhat extra about on this present just lately.
We’ve talked for a very long time about self-defense towards this terrible system. But self protection solely will get us to this point — particularly after we’re really sick, or needing assist. We’re not in the perfect place to interact in a struggle.
But we are able to struggle for one another. And you don’t all the time need to be a lawyer.
Abigail Burman: This is a service you possibly can present for folks. If you’re the form of particular person or , somebody who actually enjoys renegotiating their web plan, you’ll most likely be nice at this.
Dan: Sometimes simply displaying up is sufficient. Especially in costume.
Abigail Burman: I’ve gone and simply stood within the nook for folks to be the scary one who’s sporting a swimsuit.
Dan: And you don’t all the time even want a swimsuit. We talked just lately with an expert advocate who stated, “When I get on a call with a client and say, ‘I’m her advocate,’ I can feel the person on the other end of the line straighten up a little bit.”
And as we stated then: You don’t need to be an expert to say “I’m this person’s advocate.”
The particular person on the opposite finish of the telephone doesn’t must know you’re that particular person’s roommate, or simply their good friend.
The thought is, take what you could have — no matter data you could have, no matter expertise you could have, no matter TIME you could have, and sure no matter privilege you could have — and see in case you can put it to make use of.
Abigail Burman: You know, that this, uh, we speak quite a bit about mutual assist and networks of care and I feel it is a enormous a part of it’s simply displaying up for the forms facet.
Dan: Of course, that’s not going to make all of the distinction we want.
Abigail Burman: Looking out for our associates, serving to folks in our group is barely gonna get us to this point, we nonetheless want so many extra modifications from lawmakers to make this a system that works for everybody.
Dan: And sure, in fact that’s true. So Abigail is on the market advocating for coverage change. But as a result of none of that’s taking place tomorrow she’s ALSO displaying up proper now for folks in her life, serving to struggle one battle at a time.
So, simply to evaluation, I’m taking three large issues from Abigail’s struggle right here.
One is somewhat basket of potential instruments: Think about “network adequacy” as a requirement — your insurance coverage firm owes you a health care provider. Think in regards to the disappointed-not-angry vibe. Think about your state rep’s workplace as a potential useful resource. — and once more, we’re gonna submit a few of what Abigail has written so yow will discover it from wherever you’re listening to this.
Two: Jesus Christ, this was loads of work. Even with Abigail’s SIGNIFICANT benefits, and the assorted items of knowledge she shared about hacking by means of, this isn’t somebody most of us might simply tackle.
And three: Let’s take into consideration these as fights we tackle for one another.
That’s one thing I actually need to work towards, one thing I hope this present can do: How will we develop into a group — nonetheless large, nonetheless unfastened — of parents who might help one another HELP EACH OTHER?
It’s large. We’ll take it one step at a time.
For now, in case you haven’t already, take a look at our First Aid Kit e-newsletter. That’s the place we’ve been writing down loads of the ideas and techniques we’ve been studying about HOW to tackle these fights.
You can discover every thing we’ve written so far — greater than twenty installments to this point — at arm and a leg present dot com, slash, first assist equipment.
I’ll catch you quickly.
Till then, deal with your self.
This episode of An Arm and a Leg was produced by me, Dan Weissmann, with assist from Emily Pisacreta, and edited by Afi Yellow-Duke and Ellen Weiss — welcome aboard, Ellen!
Daisy Rosario is our consulting managing producer. Adam Raymonda is our audio wizard. Our music is by Dave Winer and Blue Dot Sessions.
Gabrielle Healy is our managing editor for viewers. She edits the First Aid Kit Newsletter.
Bea Bosco is our consulting director of operations. Sarah Ballema is our operations supervisor.
An Arm and a Leg is produced in partnership with KFF Health News–previously often known as Kaiser Health News.
That’s a nationwide newsroom producing in-depth journalism about well being care in America, and a core program at KFF — an unbiased supply of well being coverage analysis, polling, and journalism.
And sure, you probably did hear the identify Kaiser in there, and no: KFF isn’t affiliated with the well being care large Kaiser Permanente. You can be taught extra about KFF Health News at arm and a leg present dot com, slash KFF.
Zach Dyer is senior audio producer at KFF Health News. He is editorial liaison to this present.
Thanks to Public Narrative — That’s a Chicago-based group that helps journalists and nonprofits inform higher tales– for serving as our fiscal sponsor, permitting us to simply accept tax-exempt donations.
You can be taught extra about Public Narrative at www dot public narrative dot org.
And because of all people who helps this present financially.
If you haven’t but, we’d love so that you can be a part of us. The place for that’s arm and a leg present dot com, slash help.
Thank you!
“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.
To be in contact with “An Arm and a Leg,” subscribe to the e-newsletter. You may also observe the present on Facebook and Twitter. And in case you’ve bought tales to inform in regards to the well being care system, the producers would love to listen to from you.
To hear all KFF Health News podcasts, click on right here.
And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you take heed to podcasts.