US Senator Ben Ray Luján
US SENATE News:
WASHINGTON, DC – U.S. Senators Ben Ray Luján (DN.M.), Steve Daines (R-Mont.), and Tina Smith (D-Minn.) led a bipartisan letter to United Healthcare, Aetna, Anthem Blue Cross Blue Shield , and Humana regarding “ghost networks” which present a challenge for patients seeking in-network service providers.
According to a March 2022 GAO report, issues include inaccurate or outdated information about provider networks. Phantom networks occur when providers are on an insurer’s website as being in the network but are no longer in the network, not accepting new patients, or even still in business. The problem of phantom networks is particularly prevalent in mental health care and worsen during the pandemic mental health crisis, with providers quitting their jobs or stopping taking new patients due to overload.
In New Mexico, the previous state administration’s decision to dump behavioral health staff under the state’s Medicaid program drove providers out of the state and had ramifications for healthcare networks. private insurance. The bipartisan letter asks vendors for information on how they keep New Mexicans informed to avoid costly expenses.
“Ghost networks confuse and frustrate patients who often need immediate care. Patients who lack the time and resources to sift through inaccurate provider directors may ultimately choose to forego or delay needed health care. Others may be forced to pay a supplier out of pocket,” the senators wrote.
“When patients search for a provider in the network on a company’s website or directory, it is essential that they receive accurate and up-to-date information,” the senators continued.
Support groups include the Kennedy Forum, Mental Health America, American Psychological Association, National Council for Mental Wellbeing, National Alliance on Mental Illness (NAMI), Treatment Advocacy Center, and American Foundation for Suicide Prevention.
“People face so many barriers when trying to find mental health care, network directories that list ‘ghost providers’ shouldn’t be one of them. I applaud this bipartisan letter led by Senator Luján for holding insurance companies accountable and helping more Americans get the mental health and addiction care they need,” said Rebecca Bagley, President and CEO. of the management of the Kennedy Forum.
“We commend Senators Luján and Daines for their leadership in seeking this important information from insurers,” said Schroeder Stribling, president and CEO of Mental Health America. “Over the years, Mental Health America affiliates have secretly surveyed purchasers of provider directories and found high rates of inaccuracies that prevent people from getting the help they sorely need. We are grateful for this next step in resolving this pressing and persistent issue. »
Letters are available HERE and below:
We are writing to request stock information [company name] takes to comply with the requirements of the Consolidated Appropriations Act (CAA) 2021 to address the problem of inaccurate supplier directories or “ghost networks”. As you know, the term “phantom network” describes a list of health care providers that are not accepting new patients or are otherwise inaccurate. Shadow networks confuse and frustrate patients who often need immediate care. Patients who lack the time and resources to sift through inaccurate provider directories may ultimately choose to forego or delay needed health care. Others may be forced to pay a supplier out of pocket.
The problem of phantom networks is particularly acute in mental health care. A March 2022 study by the Government Accountability Office (GAO) described “ghost networks” or “inaccurate vendor information” in vendor directories where “vendors are listed… as vendors in the network, but do not do not take new patients or do not. in a patient’s network” as one of the multiple challenges consumers face in finding in-network mental health care providers. The GAO report cites recent studies showing that people who attempt to use provider directories “to schedule outpatient appointments with psychiatrists have found that inaccurate or outdated information complicates consumers’ ability to obtain care.” . Additionally, the problem of phantom networks only exacerbates the difficulty for those seeking providers who specialize in child and adolescent mental health.
Unfortunately, this problem is not new. In a 2015 study, researchers called 360 psychiatrists on Blue Cross Blue Shield in-network provider lists in Houston, Chicago, and Boston. Perhaps most troubling, of the numbers listed in the database, 16% did not belong to vendors, but instead included numbers for a McDonald’s restaurant, boutique and jewelry store. After two rounds of calls, the researchers were only able to make an appointment with 26% of the providers listed. In a 2017 study of child psychiatrists, researchers called the offices of 601 individual pediatricians and 312 child psychiatrists located in five US cities and listed as networked by Blue Cross Blue Shield. The researchers were able to make appointments with 40% of pediatricians and 17% of child psychiatrists. The study found that the most common reason for not being able to make an appointment was that the phone number listed was incorrect. In recent years, several health insurers have even been sued for phantom networks. In 2018, Aetna reached a settlement agreement with the Massachusetts Attorney General’s office after an investigation revealed several issues with their directories, including inaccurate and outdated information.
However, the problem is not limited to mental health care providers alone. A 2016 Centers for Medicare & Medicaid Services (CMS) study examined the accuracy of the locations of 108 providers selected from the online provider directories of 54 Medicare Advantage organizations. The study found that 45.1% of vendor directory locations listed in these online directories were inaccurate, including: incorrect phone numbers, vendor not in location listed, and vendor not accepting no new patients.
When patients search for a provider in the network on [company name’s] website or directory, it is essential to provide them with accurate and up-to-date information. The CAA has established standards for provider directories to protect against surprise medical bills. It required schemes and issuers to establish a process to update and verify the accuracy of the provider directory and if a service was rendered based on inaccurate information provided by the issuer, cost sharing should not exceed the amounts in the network and all amounts had to be applied in -network deductibles and disbursed. Although the US Department of Health and Human Services is responsible for promulgating rules, plans and issuers are required to implement these provisions using a reasonable and good faith interpretation of the law.
We are looking for information on your procedures in accordance with these requirements. For this, we seek answers to the following questions:
- What steps or processes [company name] take to ensure compliance with the requirements under the CAA, 2021 to proactively ensure your supplier network is up to date?
- What is the mechanics of the processes used? Do you use contractors, claims-based or other mechanisms?
- How often do you update your supplier network?
- How often do you verify the accuracy of supplier directory contact information?
- Do you proactively perform audits to determine if providers are no longer accepting new patients or staying in the network, regardless of information received from providers?
- What steps do you take if a service provider informs you that he will no longer accept new patients or that he will no longer remain in the network?
- What steps or processes do you use to proactively seek information from providers to verify if they are accepting new patients and will remain in the network?
- On average, how long does it take between acquiring information about a provider who is not accepting new patients or who has gone out of the network and removing a provider’s name from your network directory?
- What are the steps [company name] if a patient reports that a given provider is no longer taking new or in-network patients?
- What are the steps [company name] if a patient reports that a phone number or address is incorrect?
- Does your provider database reflect the availability of telehealth appointments for a given provider?
- What are the steps [company name] take to educate providers on reimbursement rates and approvals for telehealth appointments?
- In the event that a beneficiary was provided a service by a non-participating provider or facility, but the individual received inaccurate plan information in the Provider Directory, what processes are in place to ensure that the person is not charged more than a participating provider’s cost share?
- What processes exist to ensure that this amount is applied to any maximum deductible or disbursed?
Thank you in advance for your cooperation. We look forward to working with you on this important issue.