'Ghost' Provider Networks a Big Problem for Patients, Especially in Mental Health

WASHINGTON -- Nine years ago, Keris Jän Myrick had a problem: she got a new job in a new state, and with it, new health insurance, and she needed to change her mental health provider.

"Navigating the Blue Cross Blue Shield for federal employees provider directory to find a psychiatrist in the D.C. or Maryland area turned into one rejection after another," Myrick said Wednesday at a hearing on improving provider directory accuracy held by the Senate Finance Committee. "Call after call resulted in the following types of responses: 'Who?' 'He doesn't work here. No, I don't know where they are.' 'Who? I don't know who that is. I'm not sure they ever worked here' ... Or a recorded message: 'Doctor Fill-in-the-Blank is no longer accepting new patients. If this is an emergency, hang up and dial 911.'"

Short-Lived Success

After countless days and hours, Myrick said, she finally found a provider who was taking new patients, but when she told the person her diagnosis was schizophrenia, "A pause, a long silence, and then the response: 'Oh, I don't take patients with schizophrenia.' I asked if they have any suggestions or referrals to help me find a doctor who does, and the answer was, 'Check the provider directory.'" She wound up calling her former psychiatrist in California and flying back at her own expense several times a year to see him.

And Myrick is not alone, especially when it comes to appointments with mental health providers, said committee chair Sen. Ron Wyden (D-Ore.). "Last month, my staff conducted a 'secret shopper' study," he said. "They made over 100 calls to make an appointment with a mental health provider for a family member with depression, and they looked at 12 Medicare Advantage insurance plans in six states. The results were clear: our secret shoppers could get an appointment only 18% of the time. That means more than eight in 10 mental health providers listed in these insurance company materials were inaccurate or weren't taking appointments."

"Other secret shopper studies looked at commercial health insurance and found the same thing," he continued. "In 2017, researchers posing as parents seeking care for a child with depression got an appointment 17% of the time. 'Ghost networks' are an ongoing, persistent problem." The solution is "a three-legged approach. We've got to have more oversight, greater transparency, and serious consequences for insurance companies that are fleecing American consumers."

Incorrect directory information "is costly and devastating for patients," testified American Medical Association (AMA) president Jack Resneck Jr., MD. "At a time when our nation is fighting a mental and behavioral health crisis, inaccurate directories are not only an absolutely infuriating barrier for patients and families already in great periods of stress ... They help mask the fact that insurers consistently and frankly egregiously fail to provide adequate networks and comply with parity laws, causing harm to millions of Americans."

The Plans' Responsibility

Resneck, chair of the department of dermatology at the University of California San Francisco, said he conducted a secret shopper study himself a few years ago. "I had med students call every dermatologist listed in directories for many of the largest MA [Medicare Advantage] plans in a dozen U.S. metropolitan areas," he said. "They sought appointments for a fictitious patient with a severe rash, and the results were dismal. Of 4,754 listings, almost half represented duplicates. Among the remaining listings, many of those practices didn't exist, had never heard of the listed physician, or reported that they had died, retired, or moved away ... In the end, just 27% of listings were unique, accepted the listed plan, and offered an appointment."

Doctors do have a role to play in solving the problem, but the main responsibility ultimately lies with the plans, which are not making it easy for physicians to help, said Resneck. "I work at a pretty big academic medical center. You'd think our big staff devoted to this work would equate to more accurate listings, but health plans are typically taking 6 to 8 months to add or delete physicians after we notify them of changes. They don't use standardized formats, so we have to send different rosters with different formatting to each and every one. For big and small practices typically contracting with 20 or more plans, this amounts to a costly and just demoralizing administrative burden."

Robert Trestman, MD, PhD, a psychiatrist at the Virginia Tech Carilion School of Medicine in Roanoke, said that patients who had trouble finding providers felt that "it was somehow their fault." He noted that "the national administrative burden for physician practices to send directory updates to insurers through disparate technologies, schedules, and formats is $2.76 billion annually ... Not all mental health clinicians practice in settings like mine that are willing and able to invest the resources needed to participate in the networks. Private practitioners make up a significant portion of the psychiatric workforce, and many do not participate in the networks because of the administrative burden." He suggested that Congress incentivize doctors to adopt integrated care models that would help primary care physicians deliver more of the psychiatric care.

Mary Giliberti, of the mental health consumer group Mental Health America, in Alexandria, Virginia, said patients who end up seeing an out-of-network provider due to a provider directory error should not be held financially responsible. "It should not fall on the person who's least able to bear this cost. If it's not accurate, that shouldn't be their problem. They shouldn't have to pay for it."

Carrots, Not Sticks

Sen. Thom Tillis (R-N.C.) said he was "shocked" that health plans weren't doing their own internal audits of their provider directories. "Rather than mandating that, why couldn't we move towards mandating CMS [the Centers for Medicare & Medicaid Services] -- and giving CMS the resources necessary to do it -- that we're going to perform audits?"

Plans with inaccurate provider directories could be given an "F" grade and have it published on the CMS website. "I think the competitive advantage for the insurers would be, 'Go to the CMS website see our rating -- we've got an 'A' or 'B' or 'C' grade," Tillis said. "Because if we come down with a heavy hammer they're going to comply, but that's also taking their attention away from finding additional providers, driving down the cost of insurance, and a number of other things."

Jeff Rideout, MD, of the Integrated Healthcare Association in Oakland, California, told the senators about an effort in that state -- the Symphony program -- which aims to be a single-source provider directory for health plans. "Symphony creates a 'golden record' by applying a strict set of agreed-upon rules that determine what the best information is," he said. "Symphony now has 17 contracted health plans and more than 100 contracted provider organizations, and is also engaged with Covered California," the state health insurance exchange.

The organization has found that "provider data encompasses literally hundreds of specific data elements, and most need to be verified on a very frequent basis," he said, adding that providers are more likely to verify the accuracy of their data -- in this case, every 90 days -- if they can do it just once and have it apply to multiple plans. In addition, the association has found that "we need more data elements related to LGBT support; we need more data elements related to race and ethnicity. So this problem of the data elements will just grow, not shrink."

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