‘This Isn’t Just a Payer Problem’: Health Plans and Providers Must Jointly Address Ghost Networks

More than 80% of mental health provider listings on Medicare Advantage (MA) directories are inaccurate or unavailable.

That’s according to a recent secret shopper study conducted by the Senate Committee on Finance. These inaccurate provider directories, also known as “ghost networks,” can cause patients to get pinned down by large out-of-pocket bills and clinicians to miss out on potential patients. Involved parties struggle to determine the steps to take to solve the ghost network problem.

Payers and providers must collaborate to protect patients and improve the status quo for providers, industry insiders told Behavioral Health Business.


Impact on patients

Ghost networks have come under fire in US courts for misleading patients.

“When insurance companies host ghost networks, they are selling health coverage under false pretenses,” Senate Finance Committee Chair Ron Wyden (D-Ore.) said in a statement. “In any other business, if a product or service doesn’t meet expectations, consumers can ask for a refund. In my view, it’s a breach of contract for insurance companies to sell their plans for thousands of dollars each month while their product is unusable due to a ghost network.”

Patients may have to weed out many inaccurate listings before finding an in-network provider in-network. Sometimes, finding an in-network provider is impossible, resulting in larger bills.


“Within outpatient mental health especially, it’s not only taking time but also not being able to access in-network clinicians who are accepting patients,” Anisha ​​Patel-Dunn, chief medical officer of Lifestance, said. “So that’s where we’re in this very difficult situation where a lot of people are accessing care out-of-pocket for outpatient mental health.”

Lifestance Health (NASDAQ: LFST) provides virtual and in-person outpatient mental health care for children, youth and adults with several mental health conditions.

When a provider is falsely listed as in-network, patients may be surprised at the hefty bills that may arise with out-of-network costs. One study found that patients who encountered inaccuracies in provider directories were four times more likely to receive a surprise outpatient out-of-network bill.

Patients often make behavioral health appointments when their mental health is at a low point, making ghost network-related problems even more challenging to deal with.

“The hard part for patients is when you’re struggling, especially with some kind of mental health issue, it can often be really difficult to just take those steps,” ​​Patel-Dunn said. “A symptom of depression or even anxiety can be a struggle with motivation or low self-esteem and sense of self-worth. So, just getting up the gumption to make a call or reach out can take so much energy. Then to start calling and not get any appointment availability is really quite frustrating and demoralizing.”

Ghost networks’ impact on providers

Healthcare providers also face consequences due to inaccurate directory listings, including impact on bottom lines, number of patients and ability to provide a continuum of care.

Clinicians who work within larger networks can easily refer patients internally. Some providers have a solo practice or may need to refer out to a different specialty. In other instances, a particular client may not be a good match for a clinician, necessitating a referral to a different provider.

Patel-Dunn, who works with women’s mental health, runs into this problem when looking to refer a patient to a gynecologist or specific mental health clinician focusing on women’s health in another geographic area.

“I will try to go to the [insurer directory] as well and give referrals and it’s frustrating because I may not know who is accepting new patients, and even if it says they are, there’s often some inaccuracies,” Patel-Dunn said. “The reality is that we as the clinician feel the burden because we have the patient there in our office, or virtually in an appointment, and so we feel helpless. We feel an obligation to our patients to help them, and then to feel so debilitated and helpless ourselves is just really quite frustrating.”

Providers also shoulder some of the responsibility for solving the ghost network problem. Payers ping providers quarterly in an effort to update information, according to Pamela Greenberg, president and CEO of the Association for Behavioral Health and Wellness (ABHW).

“There may be a state requirement or some specific type of accreditation that’s more frequent … but at least in the one-off conversations that I’ve had with our members, they’re pinging for information quarterly,” Greenberg said. “There may even be some follow-ups there. From our perspective, if we’re not getting the information from your provider, that’s a challenge and creates a problem.”

ABHW is an advocate for insurance plans. Its member companies provide behavioral health insurance to over 200 million people.

Responding to these requests for information can be overwhelming if a practice has multiple payer relationships, Greenberg said. Still, in a perfect world, providers could help curb ghost networks by responding to these requests in a timely fashion.

“I’m not sure it’s realistic in the format that it happens now, where three or four plans the provider contracts with are all asking that same information quarterly,” she said.

Providers may not be responding to payers’ requests for data, but it’s not for lack of payer effort.

The average total cost for providers to maintain insurer directories is $63,004, according to a survey conducted by the Council for Affordable Quality Healthcare. The more payer relationships a provider has, the more that cost increases.

That brings the total spent on updating directories to $2.76 billion annually, if extrapolated to include all US physician practices.

On top of the money spent attempting to update directories, clinicians can miss out on potential clients.

Listed phone numbers or websites may be inaccurate, keeping patients from being able to contact providers.

“It’s horrific when you’re having trouble filling your schedule, but on the website, your contact information is incorrect, or the address of your location that you’re working out of is incorrect,” Patel-Dunn said.

A multipronged solution

Politicians recently took action to combat ghost network problems within Medicare Advantage (MA) plans.

​​“In the midst of a mental health and substance use crisis, people need to easily and quickly access the help they need,” Mary Giliberti, chief public policy officer of Mental Health America, said in a statement. “The federal government pays Medicare Advantage plans to provide timely services, but their inaccurate provider directories lead to frustration, financial hardship, delay, and denial of care.”

A bipartisan bill known as the Requiring Enhanced & Accurate Lists of (REAL) Health Providers Act would, if passed, strengthen requirements for MA plans to maintain accurate provider directories and require the U.S. Centers for Medicare & Medicaid Services (CMS) to publish guidance on how to keep accurate provider directories, beginning in 2026.

MA plan directories have not been audited since 2018, according to the Senate Committee on Finance.

Some businesses are taking matters into their own hands by using new digital technologies.

Lucet, a behavioral health optimization company for health plans, launched in January 2023. The company’s “Navigate & Connect” platform screens, triages and directly schedules patients into care.

On average patients who use the platform typically get an appointment in seven days, CEO Shana Hoffman told BHB.

Some digital health companies are teaming up with both payers and providers to help fill in the gaps.

Mental health provider network Headway was founded in 2019 as a direct response to challenges associated with ghost networks, according to Chief Commercial Officer Olivia Davis.

The unicorn’s digital platform helps connect patients to mental health providers in their insurance network by taking grunt work, including tasks related to real-time scheduling, electronic health records (EHR), price transparency and human resources off clinicians’ shoulders.

“The key problem that we’re talking about is a really fragmented provider community, so around 80% that are solo practitioners,” Davis told BHB.”When you’re a solo practitioner, you don’t have the back office staff to file claims to negotiate with insurance companies, etc. It’s not that they don’t want to accept insurance, it’s that they don’t have the capacity.”

What else needs to be done

Almost every party involved with ghost networks agrees that more needs to be done to fix the problem.

The status quo, in which payers approach ghost networks by hoping providers will offer up-to-date information, is “not going to work,” according to Hoffman.

“There have to be new solutions brought to the table,” Hoffman said, “rather than just continuing to beat the drum of, ‘You have to keep your provider information updated for the directory because we’re getting penalized if we don’t have it.’”

For Hoffman, both providers and payers need to make changes, but the impetus is on insurance plans.

“Payers have to start that process to say, ‘We’re gonna do things differently and we’re going to work to address this,” Hoffman said. “If [payers] extend an olive branch and a carrot to say, ‘We actually have a solution that can get you the patients that you want to see with less administrative burden,’ then the provider is more willing to lean in and say, ‘Okay, well, it makes sense for me to make sure all my information is correct, because I want to reduce the barriers for that person coming across to me.’ So I think it’s got to be a partnership.”

Payers want to correct ghost networks to avoid higher costs in the long run, according to Greenberg. 

“Plans are trying to get people into coverage as soon as they can,” she said. “You could delay their care and that’s going to result in a person being more sick. And, frankly, more costly. So we want to, for their benefit and ours, get them into treatment as soon as possible.”

“The challenge and the solutions really are payer and provider together,” she said. “This isn’t just a payer problem.”

Greenberg said  that a central, tech-enabled hub of provider information would help ease problems associated with ghost networks. 

Payers could come together to create the platform, or the government could require it.

“This can mean then that the provider would only have to go to one place to update the information, and then the plans would have to go to that one place,” Greenberg said. “That would eliminate a lot of the administrative burden for the provider and allow the plan, hopefully, to get more updated information.”

Patel-Dunn said that she would like to see the expansion of California’s SB 221 legislation, which requires health plans to have outpatient mental health and substance use disorder treatment available for members to be seen within 10 days.

The problem with the gradual adoption of legislature like SB 221, Patel-Dunn said, is that it’s slow.

Providers may need more support, Davis said. Therapists often have only accepted insurance for a few years and may distrust directories. The first step may just require more conversation between payers and providers.

“There needs to be less conversation in silos and more bringing multi-constituent parties together to jointly agree upon what we think about sharing data quality data back and forth,” Davis said. “I see a lot of siloed group conversations and not a lot of cross party conversations.”

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