Audits and AI might help deal with the problem of woefully inaccurate provider directories supplied by insurers to their members.
The U.S. healthcare system can be difficult to navigate, but experts and lawmakers alike are working to tackle at least one bedeviling problem: ghost networks.
“Ghost network” refers to inaccuracies in insurers’ provider directories. If a patient is seeking care, in theory they should be able to access a list of in-network providers accepting new patients. Problems arise when these directories contain outdated, missing or incorrect information, putting the onus on consumers to track down an appropriate provider.
When Senate Finance Committee staffers conducted a secret shopper study of 10 mental health providers in 12 Medicare Advantage plans, 80% of 120 provider listings were inaccurate or unavailable and 33% were nonworking numbers, incorrect or yielded unreturned calls. Only 22 of the listings were in-network and for providers who were accepting new patients.
“More than 80% of the listed, in-network, mental health providers that staff attempted to contact were therefore ‘ghosts,’ as they were either unreachable, not accepting new patients, or not in network,” the staffers wrote in a report issued in May 2023.
The ghost network problem is not new. Inaccuracies mean patients receive out-of-network care that can lead to higher bills. A number of studies have found that ghost networks are particularly prevalent when it comes to mental health providers.
“These ghost networks often exist due to a combination of factors, including the fact that (patients with mental health issues) are often reluctant to complain about poor network access to their employers or regulators,” explained Alan Nessman, J.D., senior special counsel at the American Psychological Association (APA), in an email exchange with Managed Healthcare Executive. “That, in turn, may be why some insurers have not felt it necessary to increase reimbursement for mental health providers despite the dramatic increase in demand for mental health treatment over the last few years,” he added.
The APA is just one of many groups calling for reform. In November 2022, Sen. Tina Smith (D-Minn.) and Sen. Ron Wyden (D-Ore.) introduced the Behavioral Health Network and Directory Improvement Act, which requires plans to carry out independent audits to ensure their networks are accurate.
The bill also mandates the federal government conduct separate audits and post their findings publicly online. It requires providers to regularly update the data they send to health plans, among other measures. In addition, the Consolidated Appropriations Act of 2023 mandates Medicaid plans publish and update accurate and searchable provider directories.
Along with improved federal standards, “it is also important to facilitate provider reporting of availability across multiple insurers since many psychologists who do remain in networks are in multiple networks,” Nessman said. “APA is advocating for simple standardized reporting for all insurers and, ideally, a national provider directory, along with an internet portal that would allow the many small practices that do not have certified (electronic health record) systems to easily connect to that directory.”
Improved enforcement of parity law and raising awareness of the problem among employers could also help mitigate the challenge, Nessman added.
Some solutions may involve artificial intelligence as a means to identify and eliminate ghost providers. Sanjay Acharya, MBA, the senior vice president of strategy and growth at HiLabs, explained how his company does just that during a recent webinar presented by AHIP,the health insurance trade organization.
“We’ve developed a capability or a product that actually looks at both the data ingestion side — taking data in through the provider roster channel to automate and quality check that data upon entry, using AI solutions that are powered by a lot of these large language models similar to what you’ve seen in ChatGPT. Then we also looked at how to cleanse and remove ghost network locations from the health plan database after (those data are) loaded,” Acharya said. “So you’re constantly checking and making sure that data that a plan is publishing are accurate in terms of directory locations.” The company has worked with a number of insurance providers to help solve the ghost network problem.
Gianna Melillo is an independent journalist in Philadelphia.