A recent lawsuit in the Southern District of New York has alleged that the health insurance company Anthem Blue and Cross Blue Shield violated state laws and committed fraud by maintaining “ghost networks” of mental health providers. Ghost networks are directories for insurance companies that contain outdated or inaccurate information about providers covered by the insurance plan. The lawsuit alleges that only seven of the first 100 providers on the Anthem directory for the state of the New York were contactable, in network, or accepting patients. This aligns with findings by the New York Attorney General that 86% of mental health care providers listed on New York health plans’ networks were ghosts. Getting stuck in a ghost network, unable to find a covered provider, can stymie a patient’s efforts to find mental healthcare, producing dire consequences.
Ghost networks exacerbate and highlight a larger issue: the shortage of mental health professionals in the United States. These shortages are often regionally concentrated, particularly in rural areas. The COVID-19 pandemic opened a new door for treatment. Not only did insurance companies start covering behavioral/mental telehealth services, but many states relaxed rules to allow out-of-state providers to treat patients remotely. In conjunction, both policies were effective in improving access to health care. However, such policies were typically effectuated through emergency order and therefore did not last beyond the end of the pandemic. Still, telehealth has remained popular.
Typically, behavioral health providers must be licensed in the state where their patient is physically located to be able to treat them. The inability to access care across state lines creates issues for several groups. First, it hurts individuals who require specialized care or are seeking competencies that may not be available in their area (like a bilingual therapist who specializes in a specific disorder). This disproportionately impacts people from rural areas or from mental health “deserts.” Second, the restriction harms people who are not geographically bound to one place, including remote workers as well as college and graduate students. Out-of-state students face significant barriers to receiving continuous mental health care as they are often not able to see their providers over extended breaks, like the summer. There can also be a lag in finding a new provider for individuals who simply move from one state to another.
Faced with the byzantine process of finding a new mental health provider and the emotional difficulty of ending a relationship with a trusted provider and building rapport with a new therapist, patients can lose momentum. In general, discontinuity in care can lead to patients stopping therapy altogether. This is a common occurrence, with 70% of therapists reporting having to stop seeing a client just because the client moved to a different state. This is concerning when client-provider fit is so important in the efficacy of mental health care.
Traditionally, providers who sought licenses across multiple states incurred financial and time costs. A second license could cost a provider hundreds if not thousands of dollars. Seventy-five percent of surveyed therapists cite time as the top barrier to getting licensed in an additional state. Recognizing these difficulties as well as the need for expanded mental health care, some states are taking actions to make it easier for practitioners to work out of state. States have started to join the Psychology Interjurisdictional Compact (PSYPACT), “an interstate compact designed to facilitate the practice of telepsychology and the temporary in-person, face-to-face practice of psychology across state boundaries.” PSYPACT functionally forms a reciprocal agreement between states which allows their practitioners to practice out of state via an interstate statutory agreement, passed by participating state legislatures. This compact serves to overcome some of the restrictions on out-of-state telehealth mental health services. This does not only overcome licensing issues, such as varying eligibility requirements or application processes, but it addresses concerns like the ability of a psychologist to be disciplined by a state licensing board for care provided out of state. A similar compact has been developed for social workers who also provide mental health services.
Forty-two states have enacted PSYPACT legislation – but large population centers like New York and California as well as health care leaders like Massachusetts are among the eight states yet to enact legislation. In 2023, legislation to join PSYPACT was introduced in New York and Massachusetts but neither has passed. States should seek to enter the PSYPACT in order to expand mental health care access across the country.
Rebekah Ninan’s (J.D. 2025) research interests are focused on the intersection of health and the law. She is interested in mass torts, drug product liability, pharmaceutical antitrust, and the administrative law that affects health-related regulations promulgated by agencies.
