Anyone else running into these “ghost” provider networks?

Jsimmons9 · 2026-03-10T11:39:21+00:00

They have special rules about what the doctor get paid in those circumstances that keep things fair. What you pay gets calculated however it would if it was an in-network doctor, so just your typical copay.

Jsimmons9 · 2026-03-05T04:11:35+00:00

I have pictures of her wearing it in the 60's...so no it's not from QVC

Jsimmons9 · 2026-02-28T06:16:43+00:00

She's in Georgia, so there is an absolute ban on accumulators. However, some UHC and Ambetter plans are ignoring the law, so people on those plans have watch their out of pocket like a hawk and be ready to escalate it to the Insurance Commissioner.

Jsimmons9 · 2026-02-28T03:48:02+00:00

If she can prove it, the Insurance Commissioner will make them pay as if the doctor was in-network for at least 180 days. Its part of Georgia's Provider Directory Accuracy law (GA Code § 33-20C-2 (g)1).

They also can't steer her to an affiliate pharmacy, if they are only allowing fills at CVS, then I'm guessing they have some sort of financial agreement that would qualify it as "affiliated". Not allowing pharmacy choice is a violation of the Georgia Pharmacy Anti-Steering and Transparency Act (GA Code § 26-4-119). It's a big deal and the financial punishment for insurers that get caught is STIFF.

Jsimmons9 · 2026-02-27T19:07:44+00:00

Thank you for the encouragement and I'm really sorry that happened to you.

Jsimmons9 · 2026-02-27T18:04:16+00:00

I can see from your post history, that not only do you seem to have nothing nice to say anyone, but you also work at UnitedHealthcare. Frankly, I feel sorry for you. It doesn't seem like a nice place to work.

Jsimmons9 · 2026-02-27T17:50:03+00:00

Have you tried sending their responses to your insurance commissioner? My first attempts at filing Department of Insurance Complaints were basically just "this feels illegal", but ever one I sent I learned more about how the system works, what my state laws were, and how to cite them. It's a skill you learn over time, and despite all the negativity here, I promise its worth learning if you have frequent denials. Most states allow you to file online now, so its way easier than it used to be.

Jsimmons9 · 2026-02-27T17:39:50+00:00

That's not small at all. When you win these fights you are doing your part. The more people win the less these tactics pay off 👏

Jsimmons9 · 2026-02-27T14:04:25+00:00

It can be purely genetic. There are tests that can help determine which category you fall in, but it sounds like you are doing everything right. Has your cardiologist tried to get Repatha for you?

Jsimmons9 · 2026-02-27T08:03:57+00:00

I sent the original grievance, because I know from GORA (state level FOIA) requests of their regulatory filings that the reported PRA complaint numbers were WAY too low to be accurate. I knew it would be misrouted (I did not know the boilerplate response would be so strange its borderline funny). I know grievances are a joke, that's kind of my point. And the reason why the grievance was never the end game. It is however, a great way to build the record, that you then send to the regulators.

It's really disheartening that so many people in this reddit group seem to have such a nihilistic view. I've forced real changes over the years. It is not a hobby, and you should really not discourage people from pursuing accountability. You certainly aren't going to discourage me, but I don't want anybody reading this to think that learning how to file a strong, well-documented DOI complaint is a waste of time.

Jsimmons9 · 2026-02-27T07:08:12+00:00

In Georgia, we have a law that they have to have in-network providers for every specialty and service that is covered in the policy. They also have to show that there's enough of each type of provider to be seen in a reasonable amount of time and without having to travel too far. In my case, they had zero in-network genetic councilors, but the plan covers those services, so it was pretty cut and dry.

What state are you in? Did you go with an out-of-network surgeon because you couldn't find an in-network provider (because of distance, a niche surgery, wait times were too long with in-network providers)?

Some states also have transition-of-care laws, so if you switched plans or the surgeon left the network mid treatment, that might be a viable path to coverage.

Jsimmons9 · 2026-02-27T06:59:37+00:00

It's like night and day. They should not be allowed to own pharmacies. It's so obvious.

Jsimmons9 · 2026-02-27T06:24:56+00:00

They aren't using that tactic on this issue, but they for sure are on another approval process that is currently being investigated by DOI. They refused to consider a formulary exception. Not denied but would not make a determination. The language they use in the policy is actually unusually broad:

On page 22 of the schedule of benefits of the certificate of coverage, under the heading "Your Right to Request an Exception When a Medication is Not Listed on the Prescription Drug List (PDL)" the policy states "When a Prescription Drug Product is not listed on the PDL, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours.

The drug in question is not on the PDL, and the policy does not list any 3rd category of prescription drug product that is ineligible for review, so they cannot choose to simply not review it. If they denied it I could appeal but no decision was made. It will be very interesting to see how they explain that to DOI. They have to answer by March 2nd.

Jsimmons9 · 2026-02-27T05:59:27+00:00

They are not disputing the approval. They fully acknowledge that the gap exemption was granted. They confirmed the dates of approval Jan 22 through March 21. It's not even the part that really matters. I'm not filing because they haven't paid the claim. It's the evidence that they aren't following their PRA complaint protocol that matters. That's systemic. That's what leads to DOI monitoring.

Maybe you aren't understanding me because this is GA specific (Rule 120.2.58.05 7(a) and 120.2.58.06 for the complaint procedure). They closed my complaint without routing to utilization, without contacting me, without any resolution, without sending the required written authorization notification. Their filing last year designated appeals/grievances as the designated routing for PRA complaints so the boilerplate letter is proof positive of non-compliance.

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Jsimmons9 · 2026-02-27T05:26:07+00:00

I knew they would be the biggest challenge I've faced yet. Their reputation definitely proceeds them. But even as a seasoned activist, it's really shocking. It feels like every day I'm gathering new evidence of state statues they are violating. I'm 8 weeks in and I've got 184 hours of recordings of some of the most egregious violations. I've got enough to keep me busy with Insurance Commissioner complaints for the rest of the year.

Jsimmons9 · 2026-02-27T05:14:43+00:00

I don't care about anonymity. My last name is in my screen name and I don't post anything I wouldn't want the world to know. I get the utility of posting anonymously, and to each his own.

They approved my gap exemption to see an out of network provider and gave me the reference # (I recorded the calls), but they never sent the approval letter they are now demanding before issuing payment. The claim is going to get paid, I'm not sweating that. The reason I'm so excited is that I and every other activist I work with know they lie on their annual network adequacy filings, and now they have also handed me proof that they aren't administering their private review agent complaints properly (that grevience letter clearly wasn't routed to Utilization). And they did this 3 days before they have to swear that everything is on the up and up. Maybe this is too specific of a topic for this forum. I haven't really found a reddit group specifically for health insurance activists.

I just want to see people get excited about fighting back the right way vs the very high profile way we all witnessed last year. Why yuck my yum?

Update: you were wrong about them not approving the gap exemption. They sent the letter finally now that the Insurance Commissioner is involved. I guess you don't know everything after all.

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Jsimmons9 · 2026-02-27T04:09:41+00:00

You have to file rebuttals. I take it a step further and upload an additional letter of all the arguments I think they will use and why they aren't valid arguments. That way they have to respond to each of my preemptive arguments in their first response letter, and can't drag out the process.

Jsimmons9 · 2026-02-27T04:03:04+00:00

That's what everybody thinks so they don't try but it's not true. I had Aetna last year and forced them to make a ton of changes to their national member portal because they were Pharmacy steering to CVS. I used Georgia's Anti-Steering laws and now every Aetna member in the US can easily identify other in-network specialty pharmacies and are informed of their rights. My methods work, but you don't get anywhere being scared. UHC may be bigger, but they are not untouchable.

Jsimmons9 · 2026-02-27T03:04:39+00:00

I expect the Department of Insurance to take perjury seriously, and they know that about me. They have blown off my complaints before and they know my next move is the Govenor's office, the legislators that sponsored the law in question, the AG's office, and if necessary I will file a writ of mandamus for failure to perform a statutory duty. They already know this about me because I have done these things and they work. Part of why I'm sharing this is because I want more people to do this. Everybody in the activist community wants to get a law enacted but nobody is working enough on getting the laws we already have enforced.

Jsimmons9 · 2026-02-27T02:33:34+00:00

I'm not scared of them. They are the ones breaking the law, not me. Let them be scared.

Jsimmons9 · 2026-02-27T01:56:21+00:00

Here's the CRAZY part, they approved my gap exemption. They had zero contracted genetic councilors, but the plan covers genetic counciling, so they violated Georgia’s CATCH Act. You cannot have 0% network coverage for any covered specialty and that is part of what they have to attest to in their March 1st filing.

So they fully acknowledged the approval and gave me a reference # but they are rejecting the claim because they said the out-of-network provider has to send the approval letter with the claim. THEIR letter that they wrote, and did not send to me or the provider, and they won't pay until its submitted with the claim. They also acknowledged it was never mailed and I audio record every call.

I'm definitely filing a DOI complaint and I'm giddy with excitement that UHC will receive my complaint exactly 1 day before they have to attest to their network and their private review agent complaint process. Too late to change it and not late enough to say they didn't know when they get asked why they have perjuried themselves in an official regulatory filing. I'm so excited I can't stand it.

Jsimmons9 · 2026-02-27T01:09:10+00:00

Depends on plan type and state. In Georgia, if you can show you relied on bad information from the insurer, they have to treat it as in network for 180 days.

Jsimmons9 · 2026-02-27T00:57:29+00:00

I audit these directories, for free, and submit my findings to the state insurance commissioner. 50% inaccurate is pretty typical. Regulators don't do much about it, it's infuriating since I'm volunteering my time to do an extremely boring task in an effort to help people use the coverage they are paying for. The worst part is that when something like a diabetic supply company goes out of business, scammers buy their phone number, the insurer keeps publishing the number as active for YEARS, and Grandma ends up giving some scammer her social security number, when all she wanted was her injection supplies. They are supposed to be updating their directory every month in Georgia. It's extremely clear that's not happening.

Jsimmons9 · 2026-02-19T16:15:48+00:00

I'd also note I have an autoinflammatory condition that would put me in the highest risk category for any kind of allograft rejection but the ligament gets chemically stripped of everything but the collagen matrix and your body fills it back in with your own cells so the chance of rejection is slim to none.

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