WASHINGTON, D.C. – January 30, 2023 – U.S. Senator Sherrod Brown (D-OH) joined a bipartisan group of senators in sending a bipartisan letter to United Healthcare, Aetna, Anthem Blue Cross Blue Shield, and Humana regarding “ghost networks” that present a challenge to patients in search of in-network providers. According to a March 2022 GAO report, challenges include inaccurate or out-of-date information on provider networks. Ghost networks occur when providers are on an insurer’s website as being in-network but are either no longer in-network, not accepting new patients, or even still in business. The problem of ghost networks is especially prevalent in mental health care and worsened during the pandemic as providers left their positions or stopped taking new patients due to overload.
“Ghost networks sow confusion and frustration among patients who are often in need of immediate care. Patients who lack the time and resources to sift through inaccurate provider directors may ultimately choose to forgo or delay needed health care. Others may be forced to pay out-of-pocket for a provider,” the Senators wrote.
In addition to Brown, U.S. Senator Ben Ray Luján (D-NM), Steve Daines (R-MT), Tina Smith (D-MN), Cynthia Lummis (R-WY), Ron Wyden (D-OR), Jeff Merkley (D-OR), Chris Murphy (D-CT), and Elizabeth Warren (D-MA), signed the letter.
A draft of a letter is below and they are also available here: Aetna, Blue Cross Blue Shield, United Healthcare, Humana, and Elevance Health.
We write seeking information regarding what actions [company name] is taking to comply with the requirements of the Consolidated Appropriations Act (CAA), 2021 to address the issue of inaccurate provider directories or “ghost networks.” As you know, the term “ghost network” describes a list of health care providers that are not accepting new patients or are otherwise inaccurate. Ghost networks sow confusion and frustration among patients who are often in need of immediate care. Patients who lack the time and resources to sift through inaccurate provider directories may ultimately choose to forgo or delay needed health care. Others may be forced to pay out-of-pocket for a provider.
The problem of ghost networks is particularly stark in mental health care. A March 2022 study from the Government Accountability Office (GAO) described “ghost networks,” or “inaccurate provider information” on provider directories in which “providers are listed…as an in-network provider but are either not taking new patients or are not in a patient’s network” as one of multiple challenges faced by consumers in finding in-network mental health providers. The GAO report cited recent studies showing that people attempting to use provider directories “to schedule outpatient appointments with psychiatrists found that inaccurate or out-of-date information complicated consumers’ ability to obtain care.” Moreover, the problem of ghost networks only exacerbates the difficulty for those searching for providers who specialize in children and adolescent mental health.
Unfortunately, this is not a new problem. In a 2015 study, researchers called 360 psychiatrists on Blue Cross Blue Shield’s in-network provider lists in Houston, Chicago, and Boston. Perhaps most troubling, of the numbers listed in the database, 16% did not belong to providers but rather included numbers for a McDonald’s restaurant, a boutique, and a jewelry store. After two rounds of calls, the researchers were only able to make appointments with 26% of providers listed. In a 2017 study focusing on pediatric psychiatrists, researchers called the offices of 601 individual pediatricians and 312 child psychiatrists located in five U.S. cities and listed as in-network by Blue Cross Blue Shield. Researchers were able to make appointments with 40% of the pediatricians and 17% of the child psychiatrists. The study found that the most common reason for being unable to make an appointment was that the listed phone number was incorrect. In recent years, several health insurers have even faced legal action over ghost networks. In 2018, Aetna reached a settlement agreement with the Massachusetts attorney general’s office after an investigation found several problems with their directories, including inaccurate and outdated information.
The problem is not however confined only to mental health providers. A 2016 study from the Centers for Medicare & Medicaid Services (CMS) examined the accuracy of 108 providers’ locations selected from the online provider directories of 54 Medicare Advantage Organizations. The study found that 45.1% of provider directory locations listed in these online directories were inaccurate including: incorrect phone numbers, the provider was not at the location listed, and the provider was not accepting new patients.
When patients search for an in-network provider on [company name’s] website or directory, it is essential that they are given accurate and up-to-date information. The CAA established standards for provider directories to protect against surprise medical bills. It required plans and issuers to establish a process to update and verify the accuracy of provider directory and if a service was rendered based on inaccurate information provided by the issuer, cost sharing must not exceed in-network amounts and all amounts must be applied to in-network deductibles and out of pocket caps. While the U.S. Department of Health and Human Services is set to promulgate rules, plans and issuers are required to implement these provisions using a good faith, reasonable interpretation of the statute. We seek information about your steps in compliance with these requirements. To that end, we seek answers to the following questions:
1. What steps or processes does [company name] take to ensure compliance with requirements under the CAA, 2021 to proactively ensure that your provider network is up-to-date?
2. What are the mechanics of the processes used? Do you utilize contractors, are they based on claims, or other mechanisms?
3. How often do you update your provider network?
4. How often do you verify the accuracy of provider directory contact information?
5. Do you proactively perform any audits to determine if providers are no longer accepting new patients or remain in network, regardless of information received from providers?
6. What steps do you undertake if a provider notifies you that they will no longer accept new patients or remain in-network?
7. What steps or processes do you employ to proactively seek information from providers to verify if they are accepting new patients and will remain in-network?
8. On average, how long between acquiring information about a provider either not accepting new patients, or becoming out-of- network and removing a provider’s name from your network directory?
9. What steps does [company name] undertake if a patient reports that a given provider is no longer taking new patients or in-network?
10. What steps does [company name] undertake if a patient reports that a phone number or address is inaccurate?
11. Does your provider database reflect the availability of telehealth appointments for a given provider?
12. What steps is [company name] taking to educate providers about the reimbursement rates and approvals for telehealth appointments?
13. In the case a beneficiary was furnished service by a nonparticipating provider or facility, but the individual was provided inaccurate information by the plan in the provider directory, what processes are in place to ensure that the individual is not charged more than the cost-sharing of a participating provider?
14. What processes exist to ensure that this amount is applied to any deductible or out-of-pocket maximum?
Thank you in advance for your cooperation. We look forward to working with you on this important issue.