This is the first of a two-part series on mental health ghost networks. In the first post, we will assess the information presented on May 3rd at the Senate Finance Committee hearing. In the second part, we will explore how CMS-mandated Provider Directory APIs can be used to support the proposed solutions.
Last week, the Senate Finance Committee convened industry witnesses and discussed the issue of mental health ‘ghost networks’ in health insurer provider directories. The Government Accountability Office (GAO) calls these ‘ghost networks’ because while payers’ directories show providers as in-network, members face barriers in accessing care from these providers, which makes them practically non-existent. These barriers can include: listed phone numbers not working, providers no longer at the practice, providers not accepting new patients, providers are no longer participating in the plan, provider is retired, or the provider does not practice at the listed physical address.
Assessing the Human Toll
The testimonies from industry experts included descriptions of the human impact of ghost networks on people in need of care. Keris Myrick, Vice President of Partnerships at Inseparable, recounted encounters with mental health ghost networks when she switched insurance. I recommend listening to her testimony at minute 31 in the hearing video. The verbal and written testimonies of other witnesses recount similar stories about barriers. Anybody who has sought mental health care, or helped a loved one who needed it, has likely encountered the same barriers when seeking in-network providers. Milliman found that 17.2% of behavioral health visits in 2017 were to an out-of-network provider compared to 3.2% of PCPs and 4.3% for medical/surgical providers. With 1 out of 4 adults reporting a mental health condition in the previous year, 40% of high school youth feeling persistently sad, and 22% considering suicide, we are in the middle of a mental health crisis. Inaccurate directories exacerbate the problem for people seeking care in a time of need.
Quantifying the Problem
During the testimonies and follow-on discussion, multiple audit reports were referenced (including new ones conducted recently by witnesses or committee members). For your convenience, I’ve collected most of the statistics here, and included links to the studies in which the audits were conducted. There are listed in chronological order:
| Study | Findings |
| Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks (2014) | 1) 45.5% of physician listings were duplicates 2) Unable to contact 18% physicians because number was wrong, or office never heard of physician 3) 8.5% of physicians died, retired, or moved out of area 4) 8.5% of physicians were not accepting new patients |
| American Psychiatric Association ‘Secret Shopper’ Survey (2016) | 1) 25% of phone numbers for psychiatrists non-responsive 2) 15% of psychiatrists listed in directory were able to schedule an appointment for callers |
| CMS Medicare Advantage Online Provider Directory Review (2018) | 1) 48.7% of directory locations had at least one error |
| Incorrect Provider Directories Associated with Out-Of-Network Mental Health Care and Outpatient Surprise Bills (2020) | 1) 53% of participants who used a mental health directory encountered at least one error 2) 26% of participants found that a provider listed in directory did not accept insurance 3) 24% encountered incorrect contact information 4) 20% reported being told that provider was not taking patients with their condition |
| Phantom Networks: Discrepancies Between Reported and Realized Mental Health Care Access in Oregon Medicaid (2022) | 1) 51.8% of providers listed in Medicaid directories had no evidence in claims during study period |
| Psychiatric Services (not yet published) Referenced in American Psychiatric Association testimony | 1) 10.6% of calls made resulted in an appointment 2) More difficult to obtain appointment w/ Medicaid 3) 18.6% of phone numbers were wrong 4) 25.5% of psychiatrists were not accepting new patients |
| Medicare Advantage Plan Directories Haunted by Ghost Networks (2023) | 1) Secret shoppers made an appointment 18% of the time 2) 1/3 of the time, the phone number was a dead end |
The obvious point is that, regardless of how you slice it, there are abundant data quality problems in mental health directories. The more subtle point is that audits were conducted in different ways. Some investigators were looking for specific errors while some were measuring the existence of any error. Some are comparing against claims data. Most are making secret shopper phone calls. It will be important to identify the optimal data quality assessment approach, and promote standardization of that practice across various federal and state regulatory regimes. This is especially important if government is serious about increasing transparency and potentially rating plans by provider directory accuracy scores. A commonly applied, easy to understand directory accuracy metric will be important to promote transparency and choice.
One other observation is that the ‘scheduled appointment’ outcome is one that is getting more focus with recent studies. The range of positive ‘scheduled appointment’ outcomes looks to be between 10% and 18% of attempted calls. This seems low, and most prospective patients would likely give up before the 10th attempted call.
We would ideally want the success rate to be 100%. It is important, however, to understand what we can reasonably expect. To understand what is possible, we should identify those payers that are positive outliers who outperform the majority, what interventions they employ, and how possible it is to scale interventions across all payers.
Additionally, we will want to standardize the acceptable time threshold for appointments (e.g., successfully scheduled an appointment in the next month). The other factor is the supply of mental health providers available to contract with a payer. This metrics may need to be adapted in light of overall provider availability within geographies (e.g., urban versus rural).
Understanding the Causes of Inaccurate Provider Directories
Participants in the hearing revisited the same themes related to the underlying causes of inaccurate mental health directories. These have been taken from a combination of written testimonies and the verbal remarks that you can watch in the recorded hearing. They have been categorized below for your convenience.
| Problem | Relevant Testimony Excerpts |
| Payers have difficulty managing directory data | “These providers had not submitted claims and billed for more than five unique individuals over a one-year period. I want to underscore that this study used claims data, which is information that every insurance company has access to if they want to verify their provider directories.” Mental Health America “While some health plans have worked towards establishing an internal source of truth, many face their own internal data silos that result in delayed updates and inaccurate data overwriting good data.” American Medical Association |
| Payers are intentionally inflating networks | “Plans have an incentive to show broad provider directories, but when there are high percentages of inaccuracies, these directories misrepresent the value of a plan and undermine consumer choice.” Mental Health America |
| Providers are not sending the right data | “Symphony market research and customer feedback suggests that without a centralized data repository that supports a multi-plan provider directory, health plans and providers will be unable to maintain accurate provider data and directories individually, even with the best of intentions.” Integrated Healthcare Association “Many practices separate their credentialing information from contracting information (about practice locations and health plan participation) and appointment scheduling data (on availability). When information is siloed, a practice may struggle to bring the disparate data together accurately and make it available to health plans and other parties.” American Medical Association |
| It is administratively burdensome to participate in payer networks | “Insurers intentionally make it difficult for psychiatrists and other mental health professionals to participate in their networks, which frequently enables them to avoid paying for mental health care.” American Psychiatric Association “The administrative burden of sending directory updates to insurers via disparate technologies, schedules, and formats costs physician practices a collective $2.76 billion annually.” American Psychiatric Association, referencing a CAQH estimate “Private practitioners make up a significant portion of the psychiatric workforce and many do not participate in the networks because of the burdensome requirements imposed by the plans.” American Psychiatric Association |
| Government is not enforcing rules already on the books | “Laws were passed in California, Louisiana and Maryland requiring accurate directories, but the problems continued despite the legislation. The researcher studying these efforts concluded that the lack of progress was directly related to weak enforcement mechanisms, minimal penalties, and the lack of critical tools to improve compliance.” Mental Health America |
| There are not enough providers | “With more than half of U.S. counties lacking a single psychiatrist, underlying workforce shortages will continue to impede patient access to behavioral health care even if ghost networks are adequately addressed.” American Psychiatric Association |
| Payers are not paying providers enough | “Plans’ reimbursement rates for psychiatric care have not been raised in decades. Meanwhile, unreimbursed time spent on administrative tasks has risen dramatically. When psychiatrists attempt to negotiate contract provisions, including their rates, plans respond “take it or leave it” even when there is a known and obvious shortage of mental health providers in the network.” American Psychiatric Association “Medicare’s process for setting rates devalues cognitive work and fails to adjust for increased demand, relying only on supply factors. In addition, researchers found that commercial and Medicare Advantage plans paid an average of 13-14% less than fee-for-service reimbursement rates for in-network mental health services while paying up to 12% more when care was provided by physicians in other areas of healthcare.” Mental Health America |
There is an interesting interplay between the first set of five causes (about the directories themselves), and the last two causes (issues that affect patient access but not the directory itself). Both witnesses and committee members remarked that these are two separate sets of problems. The first set needs to be addressed, so that we can have a better understanding of workforce and payment issues that also need to be addressed to ensure patient access to mental health care.
Contemplating Potential Solutions for Provider Directories
Multiple recommendations were made in both the verbal and written testimonies. The highlights are listed here, and they are organized below into categories for your convenience.
| Solution | Relevant Testimony Excerpts |
| More oversight | “We got started by passing the Medicaid ghost network provision into black letter law last year. This year. I want consensus on how to address ghost networks in Medicare. Many of my colleagues have expressed interest in applying these policies to commercial insurance like employer sponsored plans.” Senator Wyden “Provide the oversight, enforcement, and incentives and/or penalties necessary to result in highly accurate provider directories.” Inseparable “Implement a federally-operated mechanism (online reporting system or dedicated 1-800 number) for consumers/plan members to report their experiences of ghost networks and use this data to inform policy and enforcement actions.” Inseparable “It is possible to audit accuracies in directories and CMS has done this before and developed a composite measure of deficiencies based on how harmful the inaccuracies were to accessing care. Second, plans can improve the accuracy of their directories.” Mental Health America “Last week, CMS issued a proposed Medicaid access rule requiring states to use secret shopper surveys by an independent entity for managed care plan directories for accuracy and wait time for appointments for outpatient mental health and substance use providers and several other categories of providers. The surveys would verify active network status, street address, phone number, and whether the provider is taking new patients.” Mental Health America “Regulators should: require health plans to submit accurate network directories every year prior to the open enrollment period and whenever there is a significant change to the status of the physicians included in the network; audit directory accuracy more frequently for plans that have had deficiencies” American Medical Association |
| More enforcement | “It’s a three legged approach. You’ve got to have more oversight, greater transparency, and serious consequences for insurance companies that are fleecing American consumers.” Senator Wyden “The Behavioral Health Network and Directory Improvement Act (S. 5093), introduced last Congress by Senator Smith and Chairman Wyden, would require audits of plans’ provider directories to determine if they are accurate and if the listed providers are serving patients in-network. Importantly, it allows the Department of Labor to levy civil monetary penalties on plans and third-party administrators whose directories are inaccurate or are filled with providers not seeing in-network patients.” American Psychiatric Association “Finally, continuing to audit with no transparency or consequences was not very effective, as the average inaccuracy rate in 2018 was worse than the rate in 2016 despite CMS emphasizing the importance of this issue in several call letters and memos to plans.” Mental Health America “Regulators should: take enforcement action against plans that fail to either maintain complete and accurate directories or have a sufficient number of in-network physician practices open and accepting new patients.” American Medical Association |
| Incentives and transparency | “CMS has shown that it can develop a scoring system to distinguish among plans. This information on provider directory accuracy rates should be available to anyone choosing a plan.” Mental Health America “It is very important that plans that work hard to provide accurate directories and networks are rewarded for their efforts. The plan’s reimbursement rates, and the ease and frequency of their prior authorization process, can also influence whether providers are willing to participate in-network and plans that improve these policies also should be rewarded for their efforts.” Mental Health America |
| Virtual care | “At a time of unprecedented demand, it is imperative that we continue work to remove unnecessary barriers and ensure the continuity of care for those seeking MH/SUD services by permanently removing this arbitrary in-person requirement.” American Psychiatric Association “Congress extended the Medicare telehealth flexibilities and waived in-person requirements until 2024. Such changes should be permanent to provide greater access and Congress should incentivize states to make it easier for providers to practice across state lines.” Mental Health America |
| Streamlined, and better detailed information sharing | “While we work to better align incentives to improve provider directory accuracy, we must also do so without increasing burdensome requirements that will only weaken our mental health workforce.” Senator Crapo “Remove disincentives to clinicians joining networks. APA members also indicate that the credentialing process to join a network panel takes many months, often a lengthier delay than what other physicians experience, which again violates MHPAEA.” American Psychiatric Association “Plans also should be required on an annual basis to reconcile their directories with claims data. If a provider has not billed in the previous year, then the insurer should have to remove them from the directory and the network unless they can prove that they will begin taking patients.” Mental Health America “Health plans should make timely updates, streamline processes for practices to submit the data, permit practices to report all locations associated with a physician to enable coverage when necessary while accurately indicating the practice locations that should appear in the directories, and leverage interoperability and automation where possible so that updates are made as quickly as possible.” American Medical Association |
| Data exchange standards | “Require the inclusion of psychiatric subspecialties in provider directories.” Inseparable “In a recent response to a CMS Request for Information (RFI) seeking public input on the concept of CMS creating a directory with information on health care providers and services or a “National Directory of Healthcare Providers and Services” (NDH), the AMA doubled down on its call for increased data standardization and highlighted a lack of data reporting standards as a barrier to accuracy.” American Medical Association |
| Data centralization | “Symphony market research and customer feedback suggests that without a centralized data repository that supports a multi-plan provider directory, health plans and providers will be unable to maintain accurate provider data and directories individually, even with the best of intentions.” Integrated Healthcare Association |
| Better payment rates | “Congress should build on the targeted relief measures we advanced last year, including temporary Physician Fee Schedule support and Medicare telehealth expansion, to address these issues on a bipartisan and sustainable basis.” Senator Crapo “Insurers must design and maintain their MH/SUD networks in a manner that is comparable to their medical/surgical network. This includes how they set reimbursement rates and how they adjust rates in response to market forces.” American Psychiatric Association |
| Expand the workforce | “With projections showing that the country will still be short between 14,280 and 31,109 psychiatrists by 2025, it is imperative that we invest in additional GME slots for psychiatry and psychiatric subspecialties with residencies spread geographically in rural and urban areas alike.” American Psychiatric Association |
It will be interesting to see how proposed legislation and rule making evolve following this hearing. There seems to be bi-partisan support to solve the problem, but what subset of solutions will be seriously considered? Recent regulatory efforts driving interoperability and transparency among providers and payers may help make this possible.
In our next article, we will explore how payers’ Provider Directory APIs can be part of the solution.