Ghost Network Lawsuits, PBMs Dupe Employers, ACOs Reduce Costs

Hey all,

Happy Tuesday! The recent ghost network lawsuit highlights my frustrating experience trying to find a therapist while insured by BCBS, with dozens of calls to supposedly in-network providers who weren't actually available. I hope these legal challenges force insurers to maintain accurate directories instead of illusory networks that deny patients the mental healthcare they're paying for. Enjoy the rundown! 

Jacob Brody (Co-Founder & CEO, ZorroRX)

(Modern Healthcare) Carelon Behavioral Health ‘Ghost Network’ Lawsuit

Carelon Behavioral Health, a division of Elevance Health, is facing a class-action lawsuit alleging it falsely advertised a robust network of mental health providers to New York state employees, leading to financial harm and access barriers. The case highlights the broader industry issue of “ghost networks,” where insurers’ misleading directories violate consumer protection laws like the No Surprises Act and Mental Health Parity and Addiction Equity Act — but for Elevance NY members who have ever tried to find an in-network therapist, the only real surprise is that it took this long to sue. Full Article

(Health Care un-covered) PBMs Are Duping Business Owners and Crushing Workers

As employer health costs rise nearly 8% this year—the steepest climb in 15 years—business owners’ lack of understanding about pharmacy benefit managers (PBMs) is fueling skyrocketing premiums, with individual employee coverage jumping from $7,739 in 2021 to $8,951 in 2024 and family coverage from $22,221 to $25,572. By outsourcing complex pharmacy benefit decisions to brokers and consultants, companies have unknowingly handed control to three giant PBMs, who quietly dictate drug prices and coverage while pushing more workers into unaffordable, high-deductible plans that force them to skip needed care. If business owners really grasped how badly they’re getting swindled, they’d probably need a prescription themselves—assuming they could afford it. Full Article.

(JAMA) Long-Term Spending of Accountable Care Organizations in Medicare

A new study in JAMA found that participation in the Medicare Shared Savings Program (MSSP) by accountable care organizations (ACOs) led to significant long-term reductions in Medicare spending, with average annual per-patient savings of $142 over 3 years and $294 over 6 years. These findings highlight how ACOs—particularly physician-group and smaller organizations—produced increasingly larger savings over time, resulting in $4.1 billion to $8.1 billion in Medicare savings between 2012 and 2019, emphasizing the value of care coordination and organizational structure in healthcare cost containment. Full Article.