EmblemHealth: The Failed Calls Left Out of the Access Rate

The EmblemHealth ghost network settlement requires $2.5 million in penalties, fees and costs to resolve the New York Attorney General’s allegations about inaccurate behavioral health directories and inadequate access to care. It also requires restitution and an independent monitor. For someone who works with provider lists, access surveys or vendor reports, the central issue is familiar: what happens to the failed calls before anyone sees the success rate?

The agreement, effective February 19, 2026, is an Attorney General enforcement resolution called an Assurance of Discontinuance. It covers commercial insurance and Medicaid managed care, alongside New York City employee plans, Essential Plan, Qualified Health Plan and Child Health Plus products. The assurance puts their combined membership at approximately 1.5 million.

The agreement binds four companies: EmblemHealth, Inc.; EmblemHealth Plan, Inc., formerly Group Health Incorporated; Health Insurance Plan of Greater New York, also known as HIP Health Maintenance Organization; and EmblemHealth Insurance Company, formerly HIP Insurance Company of New York. Carelon Behavioral Health was their delegated behavioral health vendor. The Attorney General investigated the EmblemHealth companies’ directory accuracy, network adequacy and parity, meaning how behavioral health coverage compared with medical and surgical coverage.

What Is a Health Insurance Ghost Network?

A health insurance ghost network lists providers as available in-network when patients cannot actually obtain care from them. The provider may have stopped taking new patients, left the network, stopped practicing or become unreachable at the listed number.

In its December 2023 directory report, the New York Attorney General described calls to 44 EmblemHealth providers in New York City. The listings said they accepted new patients. Staff posing as family members seeking mental health care obtained appointments from only eight listings. The report classified 82% as ghosts.

Those calls tested the promise a member sees on the screen. According to the assurance, a provider listed as accepting children actually worked in a nursing home, saw only adults and did not accept outpatient clients. The Attorney General said the child-psychiatry listings remained until late 2025, even though the provider had submitted no claims to EmblemHealth from 2019 through 2024. A listing can contain a real doctor and still send a family looking for care to the wrong door.

The Survey Denominator Changed the Answer

The Attorney General alleged that EmblemHealth’s own access survey left out providers its callers could not reach. According to testimony recorded in the assurance, including those unsuccessful calls would have produced a much lower appointment-availability rate.

The assurance describes a January 2025 survey in which the company called 600 behavioral health providers to simulate a member seeking care. Its report put appointment availability within ten days at 46%. The company’s representative testified that even this result missed EmblemHealth’s standards. But the report excluded unreachable providers, despite a company policy that treated repeated unanswered calls, disconnected numbers and other failed contacts as failures to meet access standards.

The representative testified that including the unsuccessful calls would have put ten-day availability at 10%. Same survey. Different denominator.

We see the absurdity in asking whether a member can get an appointment, then taking the providers the member cannot reach out of the answer. On the Attorney General’s account, the policy recognized that those calls mattered, but the reported result did not count them.

That is why the assurance’s audit requirement is unusually concrete: every attempted contact must count, including wrong numbers, disconnected lines and unreturned messages. The remedy reaches the calculation itself.

Carelon Was the Vendor, but EmblemHealth Kept the Responsibility

Carelon had provided delegated behavioral health benefit management for approximately twenty years. EmblemHealth’s directory could send users to a Carelon webpage carrying EmblemHealth branding. The assurance says EmblemHealth retained responsibility for directory accuracy, an adequate network and behavioral health parity throughout that arrangement.

The Attorney General described a gap between promised updates and actual verification. According to the assurance, in March 2023 EmblemHealth told New York City that Carelon could turn around directory updates within one day after receiving changed information. Yet the assurance alleged that EmblemHealth failed to ensure Carelon regularly sent verification notices to every provider and stopped monitoring its behavioral health directory processes after 2020.

The assurance describes earlier warnings. A consultant reported in June 2020 that providers had no functional way to confirm or correct their information on EmblemHealth’s directory. A January 2021 company policy called for at least annual verification. The Attorney General also recorded testimony describing reluctance to remove providers because doing so would leave a smaller-looking network.

The internal question was who actually read the vendor’s work. The assurance records a question a senior compliance executive asked in late December 2023:

According to the same account, another executive responded by asking whether receiving the report made them responsible. The assurance separately described a Carelon report recording an eight percent success rate in appointment calls. These were results inside the business, alongside the public directory members were being told to use.

For a network or vendor employee, that sequence matters: a written verification policy, a report showing failed access, and uncertainty over who owned the response. Delegating the work had left the Attorney General asking what EmblemHealth did with the information it received.

Claims and Complaints Tested the Directory From Different Directions

Claims history tests whether listed providers actually delivered healthcare to members. Appointment calls test whether a patient can get in now. The Attorney General used both, then examined what happened when members complained.

From 2019 through 2024, according to the assurance, 6,475 listed behavioral health providers filed no behavioral health claim for an EmblemHealth member. Within that group, 4,495 filed no claims at all. A directory maintained without checking that activity can keep presenting an available network long after the treatment records raise questions about it.

The same method has value beyond this company. In Many Medicare Advantage and Medicaid Managed Care Plans Have Limited Behavioral Health Provider Networks and Inactive Providers, its October 2025 data brief, the HHS Office of Inspector General found that an average of 28% of listed providers in its Medicaid analysis delivered no services to those plans’ enrollees in 2023. That analysis covered 19 Medicaid managed care plans in ten selected counties.

The Attorney General had already secured a behavioral health parity agreement with EmblemHealth in 2014. The current assurance describes its requirements to reform behavioral health review processes and says it remained in effect.

According to the assurance, members lodged at least 360 complaints with EmblemHealth about directory inaccuracies or inability to obtain behavioral health treatment from 2018 through 2024. In one account the Attorney General described, a family could not obtain a psychiatrist appointment from the directory. Carelon supplied another list, again without success. Carelon then contacted additional providers itself and still could not secure an appointment.

According to the Attorney General, Carelon nevertheless called the complaint unsubstantiated because the member had not supplied the names of the providers called within the required period. EmblemHealth, the assurance alleged, oversaw and failed to address that practice. On the Attorney General’s account, the vendor had failed to find an appointment itself, then rejected the member’s account for missing paperwork.

What the Agreement Requires EmblemHealth to Change

The assurance requires EmblemHealth to verify the directory, test actual access and change how it handles complaints. Its directory obligations extend to sites maintained by vendors on the company’s behalf.

Directory Entries Must Survive Verification

The agreement requires a reporting link beside each provider listing and corrections within two business days after EmblemHealth learns of relevant changes. Behavioral health providers must verify their information every 90 days, with documented follow-up and rules for investigating or removing listings.

A provider who has submitted no claim in the preceding 90 days triggers further investigation, even if the provider attests that the listing is accurate. Implausible combinations also matter: an inpatient practitioner listed as treating outpatients, for example. The agreement requires records of additions, deletions and the reasons behind them.

Medicaid and Commercial Access Have Different Deadlines

The agreement gives Medicaid members a seven-calendar-day standard for non-urgent care and a 24-hour standard for urgently needed services. For commercial members, an initial outpatient appointment generally must be available within ten business days, with urgent care within 24 hours.

If an appropriate participating provider cannot be found within the agreement’s time frames, the in-network exception process allows care outside the network at in-network cost sharing. The agreement also requires EmblemHealth to confirm in real time that a provider can accept and treat a member before offering that provider as a referral.

For complaints, the starting point changes. The assurance requires behavioral health access complaints to be treated as presumptively valid. Expressions of dissatisfaction count without the member having to use a particular complaint phrase. EmblemHealth must track the response and follow up to confirm whether the member obtained an appointment.

Independent Review Must Reach the Source Data

EmblemHealth must conduct quarterly secret-shopper surveys and publish the results. An independent monitor must compare directory entries with verification records, review claims and examine complaint handling. Its access testing separates commercial networks from a second sample covering Medicaid, Essential Plan and Child Health Plus networks. It must also compare behavioral health with medical and surgical services on out-of-network use and provider reimbursement.

The National Health Law Program’s 2015 A Guide to Oversight, Transparency, and Accountability in Medicaid Managed Care explains why independent testing matters. Discussing external quality reviews, it identifies a recurring weakness:

The EmblemHealth agreement gives the monitor access to claims systems, verification correspondence and call recordings. That lets the reviewer compare the reported network with the work behind it. The required reports also address corrective measures, so reviewing a bad result does not end with recording it.

EmblemHealth Restitution for Failed Access

The restitution obligation covers excess out-of-pocket spending on behavioral health care through two categories. Directory Claims concern members who paid more than their in-network share because an out-of-network provider was incorrectly listed as participating. Network Claims concern members who paid more after they could not secure an appointment with an appropriate in-network provider and obtained care elsewhere.

The covered period begins January 1, 2020 and runs through the agreement’s effective date. The independent monitor decides eligibility and payment amounts. EmblemHealth must make the payments, and the monitor must report on payments and denials after the restitution process is complete.

This is consumer restitution under the Attorney General’s agreement, separate from the penalties, fees and costs. The agreement sets up that process rather than fixing a total restitution fund.

What a Network Insider Can Bring to a Whistleblower Case

Directory staff, vendor managers, claims analysts and complaint teams see different parts of the same access problem. A directory version shows what members were told. Verification logs and call outcomes show what the plan learned. Claims activity and complaint decisions can show whether those findings reached the people responsible for correcting the network.

Medicaid managed care plans receive fixed monthly capitation payments per enrollee. That payment is tied to enrollment, so a plan can continue receiving public money while members struggle to find a provider in its directory. For a possible False Claims Act case, we examine how those records connect to the representations made to Medicaid, the payments and the decisions inside the plan.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. The value of an insider’s account is knowing which report left out the failed calls, who received it and what happened next. We help you turn those connections into your strongest Medicaid whistleblower case.

You Know What the Access Report Left Out

If you worked on a directory, vendor survey or complaint process that kept reporting access people could not obtain, speak to one of our Whistleblower Experts about what the access report left out. We build the case around your knowledge of the plan and bring in Medicaid fraud whistleblower lawyers who understand network representations and delegated operations. We stay beside you as the records become a case and that case moves forward.