Payers place many resources—including time, personnel, and money—into maintaining provider networks for their plans and members. What is the intended goal after negotiating and contracting with networks? An accurate and comprehensive provider directory containing in-network clinicians and specialists that members can effectively use to “find a doctor” when they need care.
In reality, though, this is often an elusive goal. Members frequently find themselves haunted by ‘ghost networks’ – directories with listings for doctors who are no longer practicing, not accepting new patients, out-of-network, or have listings with inaccurate addresses, phone numbers, and websites. Those lists, constructed from bad or inaccurate data, contain inaccurate information that can hide network inadequacy. Patients have made lawmakers aware of their frustrations with delayed care and unexpected, sometimes life-altering surprise bills due to a ghost networks.
Lawmakers have listened. In 2023, the Senate Committee on Finance conducted a study of Medicare Advantage mental health care providers in provider directories and found that “more than 80% of the listed, in-network, mental health providers staff attempted to contact were therefore ‘ghosts,’ as they were either unreachable, not accepting new patients, or not in-network.” Results such as this have prompted legislators to propose legislation at both the federal and state level to require payers and providers to address the ghost network problem.
As patients advocate for change and elected officials take note, payers and providers should prepare for the mandates that are coming.
The following are five key considerations around legislative efforts to address ghost networks and improving transparency in provider directory data management.
1. Federal Efforts to Combat Ghost Networks Are Underway
Two companion, bi-partisan bills have been introduced in both the U.S. Senate and House of Representatives to address ghost networks at the federal level for Medicare Advantage (MA) beneficiaries.
- In October 2023, U.S. Senators Bennet, Tillis, and Wyden introduced the REAL Health Providers Act. This bipartisan bill, which was approved unanimously by the Senate Finance Committee, mandates that MA plans maintain accurate and updated provider directories, ensures seniors do not pay out-of-network costs for incorrect ghost listings, and instructs CMS to post publicly the provider data accuracy scores of MA plans.
- In March 2024, the House version of the REAL Health Providers Act, H.R. 7708, was introduced by a bipartisan group of legislators. Like its Senate counterpart, this bill aims to protect seniors against surprise bills from providers they thought were in-network and aims to eradicate inaccuracies in provider directory listings.
And, ghost network legislation is not limited to MA plan enrollees. The Senate has also taken on ghost networks in private health insurance.
In March 2024, Senators Smith and Wyden introduced a bill focusing on behavioral health and insurance coverage. The Behavioral Health Network and Directory Improvement Act focuses on improving provider directory accuracy, ensuring that directory update are done in a timely manner, addressing network adequacy shortcomings, and working toward mental health parity.
2. State Legislators Are Also Viewing Ghost Networks as an Election Year Issue
In addition to Congress, several states—New York, California, New Jersey, Illinois, New Jersey and New York, to name a few—have also introduced legislation to combat ghost networks. And some of these proposals are more stringent than the Congressional proposals. For example, California’s proposed bill mandates investigations of reported inaccuracies and levies steep fines for non-compliance, whereas Illinois’ proposed legislation requires updates within two days of being notified of the need for a change. Plans should be mindful of this ever-evolving state landscape as well when developing their future provider directory strategies.
3. The Momentum for Change Is Likely To Increase
Current proposed legislation evolved out of concerns for access to behavioral health care. It is likely, as momentum builds, that the language from these bi-partisan proposals will be used as a template for broader reforms focused on improved provider directory data management, shorter timelines for provider data updates, and more robust network adequacy across many types of insurers and plans. However, inaccurate provider data remains rampant at health plans, significantly affecting the overall member experience. Therefore, stopping at behavioral health reforms alone will not suffice to enhance member experience across the board.
Providers and payers should continue monitoring evolving legislation and work to address the upcoming anticipated legislative changes. Then can then develop new strategies to optimize workflows, remove data gaps and inaccuracies, and improve network adequacy.
4. The Best Defense Is a Good Offense
Payers would benefit from developing a comprehensive approach to addressing the changes to come. Health plans should strive to enact systematic fixes to improve their provider data management systems and processes. As part of this process, payors should be mindful of the following requirements that are common among many of the legislative proposals:
- Regular provider directory verifications – Plans must verify the accuracy of provider directory data every 90 days.
- Provider directory currency – Plans must keep certain categories of provider directory information up-to-date including name, specialty, contact information, address, people with disability accommodations, cultural and linguistic capabilities, and telehealth capabilities.
- Fast updates for inaccurate or outdated information – Plans will be given a short deadline (e.g., 5 days) for updating provider directory information and removing providers who are no longer in-network.
- Publicly available accuracy scores and audit results – Plans should be mindful that the results of their annual provider data accuracy assessments are likely to be made public and will be considered by members during open enrollment periods.
- In-network rates for the care provided by physicians listed as in-network – Plans willl be required to charge in-network rates for any care received by members by out-of-network providers who were listed as in-network at the time care was sought.
5. Work on an Action Plan for Data Governance Now
Payers should anticipate these new proposals and understand how they will impact their operational workflows and strategies for managing provider networks.
As part of that strategy, plans should consider the impact of ghost networks on member satisfaction. Member experience and data quality impact HEDIS scores and Star ratings. Improved data governance, interoperability, and a renewed focus on provider data accuracy will positively impact both.
To address these concerns and prepare for upcoming changes, payers should:
- Examine their current approach to provider data management – Traditional manual approaches of call campaigns, manual roster intake, and attestation will not be robust enough to handle the quick turnarounds, data standardization, and data accuracy benchmarks set by the new legislation.
- Determine areas for improvement – Identify which processes do not align with the new requirements. Accuracy score reporting, data processing times, and rapid updates will require new technology-based approaches for the creation and maintenance of accurate provider directories. Payers should examine current processing times, compliance attestation processes, and data standardization methodologies to see if they are adequate for the new legislative requirements.
- Capitalize on technology-based processes, including AI, to boost accuracy scores and achieve compliance – Manual processes will not provide the agility or accuracy required by the current legislative proposals. Plans should look to technology-based solutions to provide the processing capabilities needed to identify and clean up inaccurate data, remove directory ghosts quickly, and increase overall accuracy scores.
Accessible healthcare is at the core of efforts to eliminate ghost networks and improve the member experience through accurate and reliable provider directory listings. Once existing data is accurate, plans can build out their networks to meet adequacy requirements and ensure members have access to the right providers when and where they need care.
Legislative efforts are driving change – plans should start planning now and explore technology-based solutions to help them improve performance, achieve compliance, and most importantly, streamline the ability of their members to obtain the care they need.
About Meghan Gaffney
Meghan Gaffney is the CEO and co-founder of Veda, a healthcare-focused data automation company solving complex payer and provider data challenges.