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
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
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
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
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
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
"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
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."