How insurance companies fill their networks with ‘ghost’ therapists

The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral health issues. It is funded by Ballmer Group, a national organization focused on economic mobility for children and families. Additional support is provided by City University of Seattle. The Seattle Times maintains editorial control over work produced by this team.

If you’ve tried to find a therapist recently who fits your specific needs, takes your insurance and has an immediate opening, you already know it can be as rare as an orca spotting. 

But just how hard is it? The Seattle Times tried reaching 400 different therapists to find out.

Insurance companies maintain lengthy lists of medical professionals, including therapists, who are in their networks. We examined insurance companies’ websites, the same ones that patients encounter, calling the top 50 results that appeared when searching each insurer’s directory from different Seattle ZIP codes.

Of 400 therapists, just 32 confirmed openings for new clients seeking outpatient mental health counseling. Within that group, 13 required a referral from within a larger network, like the University of Washington Medical Center, or establishment of primary care, like at Neighborcare Health, leaving 19 with true availability for a general patient.

Another 38 confirmed they were not accepting new clients. In many cases, providers never responded; in interviews, many therapists said they only call people back if they have availability. 

None of this information, though, would be readily apparent to a prospective patient looking through their insurance company’s website to find care (which is how many experts recommend clients conduct their search). While some websites noted whether therapists were accepting new clients, calls showed that information was often incorrect or misleading.

Insurance carriers are supposed to maintain a “sufficient” network of health care providers in a health plan under Washington law, so members can access care in a “timely manner” and have a reasonable opportunity to obtain help in-network. But The Times’ analysis revealed the directories to be disorganized and difficult to decipher. 

We surveyed lists of therapists from four of the largest insurers in Washington — Premera Blue Cross, Regence BlueShield, UnitedHealthcare and Molina Healthcare — between July and September. 

Insurance companies acknowledged challenges in maintaining their directories, saying they struggle to get providers’ help in updating listings. Some support creating a national directory to ease the burden and give insurers and providers a single place where they can update and verify information.

For now, though, chaotic and unreliable lists can leave patients in the lurch, scrambling to find an appropriate and affordable therapist and delaying their ability to find mental health treatment.

Options for urgent mental health crises

For people needing care but struggling to connect with a therapist, many clinicians shared phone numbers that can provide immediate mental health support:
Life-threatening mental health concerns: Call 911
24-Hour Crisis Line: 988
Crisis Connections: 866-427-4747
King County Crisis Line: 206-461-3222

“I understand how frustrated people feel about being able to find a provider,” said Jael Weinberg, a licensed mental health counselor and registered art therapist in Seattle. “Waitlists are so long, and that just feels like a kind of heavy blanket. When you’re in the place of needing support, doing logistical problem-solving is incredibly difficult.”

Network discrepancies

The insurance companies’ lists often repeated names, listing both the individual and their practice name separately. At least 16 providers were no longer with the listed practice, The Times learned. In at least seven cases, either a wrong phone number was listed or the phone was disconnected.

Many listed providers were specialists, only working with patients like people with eating disorders or children. A few were listed as school staff. Some said because they are in leadership positions, their role is to oversee other clinicians and not necessarily accept new clients of their own.

For someone looking for a provider who shares their racial or ethnic background or understands their sexuality or gender identity, it can be difficult to determine that information from the insurance directories or even by phone. Photos were typically not available on insurance websites, and for large groups, the phone operator is not always aware of provider demographics. 

Jami Benson, a 44-year-old Federal Way resident, said she called 15 providers listed in-network with her insurer over a two-month period to find a therapist who could understand her needs as a tech worker and member of the LGBTQ+ community. 

“It was barrier after barrier,” she said. 

Nine people did not respond, and two said they could not provide her services. Among the four responding clinicians, “all of them said they were accepting new patients, but there was no caveat to say, it’s going to take six months to get you in. So I think it’s really mislabeled.”

Benson finally found a “really great” counselor but is paying out of pocket, at a rate of $150 per session, because she is outside of her insurance network.

In The Seattle Times’ analysis, UnitedHealthcare’s lists and therapist availability were particularly difficult to assess: Of the dozens of search results that came up first in Seattle searches, nearly all were therapists affiliated with Alma, a national mental health provider search platform.

The Alma therapists were listed with a Bellevue office address, but Alma spokesperson Trinity Griffin said the platform is designed to help therapists offer telehealth services — about 95% of people within the platform provide virtual mental health care.

The listed Bellevue address is “used for administrative purposes and is not an in-person location where providers physically practice,” she said in an email, adding that the company will review how providers are appearing in UnitedHealthcare’s directory.

Optum Behavioral Care, which spokesperson Christine Hauser said is part of UnitedHealth Group, said the company has expanded telehealth services to “improve access to quality care” but did not address specific questions about its use of Alma therapists.

This discrepancy between the lists insurance companies keep and what patients actually encounter when trying to schedule appointments is sometimes referred to as a “ghost network.” 

It’s a problem particularly tied to mental and behavioral health; as opposed to some other types of health care, many mental health providers work independently, without the administrative backing of a larger clinic or hospital to help them keep up with directory listings or easily refer a patient to another provider at the same office. A lack of mental health providers in general means many don’t have room for new clients. 

And because mental health care is so personal, said Sarah Applegate, a nurse practitioner at a psychiatric office in Bellevue, patients need to have ample options to be able to choose a provider “who feels like a good fit.”

“Mental health care isn’t like seeing a gastroenterologist,” she said. You might want the latter to have a nice bedside manner, but “ultimately, you don’t need to be able to pour your soul out to them.”

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The staff of Sen. Ron Wyden, D-Ore., worked to quantify the scale of the problem earlier this year. Similar to The Seattle Times’ survey, they conducted a study of 12 Medicare Advantage insurance plans in six states by making over 100 phone calls in April to create an appointment for a family member with depression. 

The “secret shoppers” were only able to get an appointment 18% of the time. In one-third of cases, the phone number was a dead end. His staff could not make one successful appointment in Oregon, his office said.

“When someone who’s worried about their mental health or the mental health of a loved one finally works up the courage to pick up the phone and try and get help, the last thing they need is a symphony of ‘please hold’ music, non-working numbers, and rejection,” Wyden said in prepared remarks for a Senate Finance Committee meeting on ghost networks, which he chairs.

He said eliminating ghost networks will require “more audits, greater transparency and stronger consequences for insurance companies that don’t keep their directories up to date.”

Wyden has also worked with other lawmakers to draft legislation aimed at cracking down on ghost networks. In 2022, he and Sen. Tina Smith, D-Minn., introduced a bill requiring health plans to conduct independent audits of their provider networks. And earlier this year, Wyden and Sen. Michael Bennet, D-Colo., sponsored legislation that would have required Medicare Advantage plans to maintain accurate and updated provider directories. Neither bill has moved forward.

In surveying the insurers’ directories, The Times left messages and called back unanswered phone numbers at least twice, and sent emails when possible for large groups with automated messages.

In the search, 10 people said they keep some kind of waitlist, with average times ranging from a few weeks to several months. Another six said they don’t keep a list but encourage people who are interested in their services to call back every few weeks to see if slots have opened. 

“I do not have a waitlist because then I feel like I’m keeping people from finding somebody else, and it’s unpredictable how long I would keep them waiting,” said Lila Vigder, a Seattle psychologist. 

Others don’t keep a waitlist because they said people sat for too long without ever moving off and they felt overwhelmed by the constant demand.

“It’s so much to even just respond to all of the people to say, ‘I’m sorry, I don’t have space,’ ” said Kendra Appe, a licensed mental health counselor in Seattle.

Stacy Lenny, a clinical social worker and therapist in Seattle, said she prioritizes previous clients in her schedule, keeping space if they need to come in for a short-term pickup. For someone who calls out of the blue, it can take up to a year to get in.

Several providers mentioned that late summer and early fall are good times to look for a provider, as many clients who are in school cycle off their schedule, and they have new openings. Some said they are more likely to update their profiles on Psychology Today, a nationwide directory of therapists, and urged prospective clients to look there for more accurate information.

No surprises?

In theory, these lists shouldn’t be so messy and inaccurate.

Congress in 2021 approved the No Surprises Act, which requires health insurers to update their provider directory information at least every 90 days. 

Regence and Premera said they do fulfill those requirements, contacting providers through email, mail, phone calls and faxes to seek updated information, including whether they are accepting new patients. Clinicians have multiple options, including online forms, to respond.

The problems are more systemic: Providers are juggling responding to multiple insurance companies in the midst of maintaining a busy practice, and insurers have limited staff to handle communicating with providers.

Among Regence’s behavioral health providers, who spokesperson Ashley Bach said are contacted once per month by email, the response rate is only 10%.

Providers who haven’t responded to Premera’s information requests in more than 18 months are removed from the member-facing directory, said Nathan Johnson, vice president of integrated products at Premera Blue Cross, but can be reinstated upon reply. 

Regence and Premera spokespeople said they would support a national provider directory that could allow clinicians to update their information for payers in one place. The Centers for Medicare & Medicaid Services is exploring the creation of a national directory of health care providers.

Johnson said his company is making efforts to proactively help connect patients with behavioral health providers, pointing to a “matchmaking” service that Premera began in 2020. “There’s a whole team,” he said, that “comes up with a list of providers who fit the interests of the particular member and who have confirmed availability of appointment.” The program is embedded in “most” fully insured plans in Washington and is available as an add-on for self-funded plans.

Mental health resources from The Seattle Times

Kaiser Permanente, another of the state’s largest insurers, was not included in The Times’ analysis. It operates with a network that’s mostly closed, meaning members are typically matched to providers internal to Kaiser’s system, or specifically contracted through an external network — a model that makes it challenging to assess therapist availability. Kaiser Permanente spokesperson Jessica Knapp said in an email that members are “generally able” to get an appointment for care within 10-15 days, but could not share data around how often that happens. 

An analysis of complaints to Washington’s Office of the Insurance Commissioner between 2019 and 2023 showed at least 39 people, including members and providers, reported difficulty getting a timely appointment for mental health care within Kaiser’s network.

In response to OIC inquiries, Kaiser “noted a national shortage of mental health providers.” The company said it was attempting to hire more behavioral health providers, and in the last year, added 62 new providers in Washington, Knapp said. 

Molina Healthcare, which administers Medicaid plans in Washington, did not respond to multiple requests for comment.

Many providers interviewed confirmed they do receive regular requests from insurers to update their information. The problem, said licensed clinical psychologist Angela Agelopoulos, is that provider availability can change on a day-to-day basis. However, the system many insurance companies use — emailing a form, with providers filling it out and sending it back and insurers updating — doesn’t keep up in real time.

“You can’t simply call and talk to the people that you need,” she said. “By the time they put that information in, we don’t have that opening anymore.”

It would be much easier, she said, for insurers to develop a database where each provider can update their own information and profile in real time. 

She’d know. Agelopoulos, a licensed clinical psychologist and owner of the therapy practice Seattle Counseling and Wellness, has been looking for a specialized therapist for her son, and only one provider is in-network, on her plan and in her neighborhood. She’s been on a waitlist for two years and calls every four months to check availability.

“I love being a psychologist,” she said, “but I really hate insurance.”

Filip Timotija contributed reporting.

This article was supported by the Journalism and Women Symposium Health Journalism Fellowship, with the support of The Commonwealth Fund.