Addressing Ghost Networks in Mental Health Care
By Hannah Rahim
Many mental health provider directories for private and public insurance plans contain inaccurate or outdated provider information, which creates a misleading illusion of accessible care. These ghost networks result in many patients being unable to access essential mental health care. To tackle this issue, federal and state governments should strengthen the regulation of insurance networks and insurers should address underlying causes of inadequate networks.
Ghost networks
We are facing a crisis in access to mental health care in the U.S. – more than half of adults experiencing a mental illness (over 28 million individuals) are without treatment. One contributor to this crisis is the existence of ghost networks – insurance networks that contain inaccurate listings of health care providers who are not actually available for appointments (e.g.: not accepting new patients, retired, moved away, or no longer accepting the particular type of insurance).
To assess the prevalence of ghost networks, Senate Finance Committee staffers conducted a secret shopper study of 120 mental health provider listings across 12 Medicare Advantage plans. Staffers, pretending to be patients, were only able to make appointments with providers 18% of the time. Over 80% of the listed providers were “ghosts” as they were either unreachable, not accepting new patients or not in-network.
The Seattle Times conducted a similar secret shopper study for private insurance companies, calling 400 mental health providers from four of the largest insurers in Washington. Only 32, 8%, offered an appointment. The researchers noted that the directories often listed repeated names, providers who no longer worked with the listed practice, incorrect phone numbers, and providers who held leadership positions in health care organizations and did not see patients.
Given the limited availability of appointments with in-network providers, patients often have to go out of network and face higher costs, or may not be able to obtain care at all. Considering these substantial consequences for patients’ access to mental health care, developing solutions to prevent ghost networks is critical.
Federal legislative solutions
The federal No Surprises Act, approved in 2021, mandates that health insurers update the information in their provider directory at least every 90 days. While many insurers attempt to comply with this requirement, systemic problems like a lack of staff to communicate with providers and providers being overwhelmed with other administrative burdens prevent full compliance. The Consolidated Appropriations Act of 2023 requires Medicaid plans to publish and update accurate and searchable provider directories. However, federal enforcement is limited and the Act does not include a private right of action, which is important to allow ordinary citizens to bring claims in court.
In November 2022, Senator Tina Smith (D-Minn.) and Senator Ron Wyden (D-Ore.) introduced the Behavioral Health Network and Directory Improvement Act, which would enforce directory adequacy standards by requiring insurers and the federal government to conduct separate audits as to the accuracy of provider networks and to publicly share their findings. The bill also requires providers to regularly update the data that they send to insurers and would establish ombudsman programs to educate individuals on their rights under the federal mental health parity law. If approved and enforced, this bill would take significant steps to prevent the existence of ghost networks.
In addition, Congress could create penalties for insurers whose networks exceed a given threshold of inaccuracy. Congress could also establish requirements for how insurers collect information from providers to ensure consistency and thoroughness.
Alternatively, the federal government could develop a national provider directory in which mental health providers could update their information for all insurers in one place. Insurers could then use automated systems to copy information from relevant providers into their own directories.
State legislative solutions
Given the current lack of federal enforcement of network accuracy, states are the primary enforcers of both state and federal regulations of provider directories. Many states have developed network adequacy standards that require a sufficient number and geographic distribution of mental health providers in a network to ensure reasonable and timely access to care. States should also establish directory accuracy standards that include percentage accuracy targets for insurer directories, reporting requirements for accuracy, and procedures for enforcing these standards.
If the federal Behavioral Health Network and Directory Improvement Act does not pass, states should adopt similar legislation such as requiring plans to audit their directories. States should also take steps to empower patients to report inadequate networks to employers or to regulators.
Role of insurers
Beyond complying with network directory regulations, insurers should take proactive steps to address the underlying causes of ghost networks. To remedy issues of data quality and integrity, insurers could use algorithms or AI to detect and remove ghost provider entries.
Insurers should also work to decrease the shortage of mental health care providers in their networks. Ghost entries would be less problematic for mental health care access if there were a sufficient group of actual providers who could accept patients. A key reason why many mental health providers do not join insurance networks is low reimbursement rates by insurers for mental health care. Reimbursement rates for mental health care are less than for other specialties and these rates have not increased in decades. Both private and public insurance reimbursement rates are not comparable to what mental health providers could make if they charged patients out-of-pocket. For instance, a psychiatrist could make two to three times more by charging a patient out-of-pocket compared to taking Medicare or Medicaid. By increasing reimbursement rates, insurers could attract more mental health providers to join their networks.
In summary, federal and state governments along with insurers should develop solutions to reduce ghost networks in mental health care. Doing so will be an essential aspect of combatting America’s mental health crisis.
