Navigating Policy Terrain: Perspectives for Payers on Tackling Ghost Networks

It’s not uncommon for a patient, when searching their insurer’s provider directory, to find listings for physicians who are no longer practicing and no longer in-network, as well as inaccurate addresses, phone numbers, and websites. These phantom entries create “ghost networks” in health insurance.

For more than a year ghost networks have made headlines as an increasingly serious issue for payers, providers, and especially patients. Riddled with inaccurate data, these networks often lead to delayed care and surprise bills, significantly impacting member experiences and trust.

Frustrated patients have been contacting their elected officials to address the ubiquity of ghost networks. Legislators have been hearing from constituents that this problem is impacting patients’ lives and ability to get care–and they are doing something about it. Three bills–two in the Senate, and one in the House–have been proposed that specifically address inaccuracies in health insurance provider directories, with more stringent guidelines, tighter timeframes, published scores, and possible fines if providers fail to keep their directories compliant.

Payers have good reason to prepare for any regulation changes now as the traditional means of checking directory accuracy–call campaigns, attestations, or manual roster intake–are cumbersome and costly processes that have not proven effective. What is proven? Automated solutions to meet the implementation windows and level of accuracy these new bills propose.

Policy reform initiatives

Three recent legislative efforts are aimed at addressing the root causes of ghost networks and enhancing healthcare access for patients.

U.S. Senators Michael Bennet (D-CO), Thom Tillis (R-NC), and Ron Wyden (D-OR) introduced the REAL Health Providers Act in October 2023. The bipartisan-supported bill is backed by the Senate Finance Committee and aims to ensure that Medicare Advantage plans keep accurate directories and protect their members–most of them seniors–from receiving surprise medical bills.

The House version of the REAL Health Providers Act – H.R. 7708 – was introduced in March 2024 by Representatives Greg Murphy (NC-03)  and Jimmy Panetta (CA-19), among others. It mirrors the language in the Senate bill and aims to protect seniors from delayed care and unnecessary costs.

Also in March 2024, Senator Tina Smith (D-Minnesota) joined Wyden to introduce the Behavioral Health Network and Directory Improvement Act. This bill addresses the problem of ghost networks for people enrolled in private health insurance plans with a focus on mental health care and coverage. In addition to targeting network directory accuracy, timeliness, and adequacy, it also aims to improve mental health providers’ network participation by establishing parity for mental health and physical health reimbursements.

Regulatory compliance

To stay ahead of policy changes, payers can track evolving requirements and compliance standards governing provider directory accuracy and network adequacy.

Here are the common themes among the proposed legislation

• High accuracy benchmarks– this includes:
  • Periodic accuracy verification: Health plans must verify their provider directory data every 90 days and, if necessary, update that information
  • Public accuracy disclaimer: If a health plan cannot verify the data, the plan must indicate in its directory that the information may not be valid. 

• Detailed provider directory information that must be kept current– Health plans must keep certain information in their provider directories up-to-date, including a provider’s name, specialty, contact information, primary office or facility address, availability, accommodations for people with disabilities, cultural and linguistic capabilities, and telehealth capabilities.

• Speedy processing turnaround times and rapid removals and updates to inaccurate or outdated information. For example, health plans must remove a provider within 5 business days if the provider is no longer participating in the plan’s network.

• Publicly available accuracy scores and audit results – these include:
  • Annual Accuracy Assessments: Health plans must analyze their provider data accuracy annually and submit a report to HHS/CMS with the results of that analysis. 
  • Public Accuracy Scores: Based upon the annual accuracy assessments submitted by health plans, HHS will make accuracy scores publicly available.

• In-network rates if directory information is inaccurate: If an MA member receives care from an out-of-network provider that a health plan’s directory indicated was in-network at the time the appointment was made, the plan may only charge that patient in-network prices. 

Make an action plan

Payers must anticipate these emerging policy trends and regulatory developments, as they will no doubt impact payer strategies and operational workflows in managing provider networks. Also, these compliance changes create the perfect opportunity to help your organizations get even better with their data, to improve member and patient experiences. Payers can break this process down into three steps:

1. Examine your current approach

It is unlikely that traditional, manual approaches to provider data accuracy–such as call campaigns, manual roster intake, and old-school attestation–will help payers reach the necessary level of compliance.

Payers need to scrutinize their current approaches to information gathering, whether it be using attestation from provider rosters or industry portals, call campaigns, roster intake, or other manual or automated efforts. What are you doing, and how well is it working? Across the industry, we see about 20-30% of provider organizations are not responsive to questions about demographic changes or requests to provide data on a regular basis.

Call campaigns are costly and time-consuming, and with a high level of variability and inaccurate results. Two different people from the same call center can contact the same practice on the same day and get different answers each time. In addition, phone calls have become an outdated, inefficient method of gathering information. They are invasive and abrasive, and therefore often ignored. It may be possible to do away with phone calls completely by relying on more technologically advanced approaches. The rostering process is difficult for both provider organizations and health plans– it’s a heavily manual process on both sides; there are significant delays in data updates; and it’s a source of provider abrasion.

2. Identify what does not align with new requirements

Processing times and mandated display of accuracy scores will require a new, technology-based approach to accuracy. Currently, health plan information processing times are too slow and accuracy verification isn’t robust enough.

The attestation that is necessary for compliance takes a long time and is not sufficient to create the required updates in a timely manner. Payers need to measure all these parts of their workflows to see where results are compliant and where they might need to change processes to stay ahead of the new legislative requirements.

3. Incorporate technology-based, non-manual solutions into provider directory management systems to boost accuracy scores

Health plan members rely on the utility and accuracy of provider directories. There are now tools that allow both health plans and provider organizations to quickly screen their entire network of information for accuracy and identify where ghost networks exist.

Once payers have uncovered inaccuracies in their directory data and “decluttered” the ghosts, they can move to the second step: examining the adequacy of the remaining information in their directories. Technology tools exist that can help fill these gaps by identifying active, in-network providers who are taking new patients.

Technology-based, non-manual tools are available to address both accuracy and adequacy gaps, from front end to back end in provider data systems. How could an AI/machine learning model identify accurate provider data, when information directly from the provider is often inaccurate? A supervised learning-based model learns the answers that a patient would get if they were trying to make an appointment and ingests all of the information that a provider creates in their daily workflow.

Machine learning models look at all of this information and can accurately predict the right answer to a higher degree of accuracy than manual outreach and other traditional methods of attestation. The models are frequently tested and recalibrated to ensure they’re performing at the optimal level. They can even accurately predict the results of a CMS audit within a 5 percent margin of error. Such models could be part of a health plan’s overall provider data strategy to ensure that information is correct and up-to-date every day. 

Legislation currently in the works about ghost networks involves some big changes for health plans, but payer organizations don’t have to tackle them alone; there are opportunities for partnerships to ease the transition into a technology-based approach to these new regulatory requirements.

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