Have you come across the term “ghost provider”? A ghost provider is a healthcare professional listed in a health plan’s provider network but is not actively participating or accepting members under that plan. Often, these inaccuracies in provider directories arise due to the challenging and labor-intensive process required for both providers and payers to maintain up-to-date, online information. These discrepancies are primarily a result of insufficient manpower and coordination among provider data teams, credentialing departments, and claims departments within payer organizations. Unfortunately, the consequence of these outdated listings falls heavily on the members.
With the rise in value-based care models and changes to the ways providers are paid for serving members, incentives to keep their data up to date are not always aligned to the payment model. For example, many managed Medicaid providers are listed in state provider directories but are not accepting new patients. This situation disproportionately impacts vulnerable populations navigating the intricate healthcare system in search of medical assistance.
The Problem:
Research indicates that provider health directories frequently contain errors. In fact, according to a study from Bloomberg Law, more than 80% of physicians have inconsistent or inaccurate entries in health insurance provider directories. Doctors may be incorrectly listed as accepting certain patients or plans they have disengaged from. This discrepancy is often due to staffing constraints as provider contracts change, but intentional misinformation for competitive advantage is also a contributing factor. Both scenarios jeopardize patient care.
Members of health plans face financial, medical, and emotional hardships when billed at higher out-of-network rates due to inaccurate provider listings. Although regulations now impose stricter penalties on health plans for maintaining phantom networks with ghost providers, the ultimate solution lies in technological advancements to modernize how provider participation is tracked, verified, and communicated. Health plans must invest in automation, workflow enhancements, and continuous electronic monitoring to address this issue effectively.
For commercial and self-insured insurance members, visiting a ghost provider expecting in-network coverage can result in substantial surprise bills due to out-of-network charges. They may receive balance bills from providers for the remaining amount not covered by insurance.
Real-life Scenarios:
Consider these scenarios illustrating the consequences of ghost providers and inaccurate directories:
- Dr. Jones, who terminated his contract with Blue Cross over a year ago due to low reimbursement rates, is still listed as an in-network primary care provider on the Blue Cross website. A patient seeing Dr. Jones expecting to pay in-network rates receives a significantly higher out-of-network bill instead.
- Memorial Hospital appears as a participating provider in Acme Health Plan’s online search for their self-insured health plan. A patient undergoes surgery at Memorial Hospital only to discover later that the hospital had not renewed its contract with Acme, resulting in unexpectedly high costs.
Fraudulent Practices:
The misrepresentation of provider network status by health insurance companies or providers can be deemed fraudulent when there is evidence of intentional deception.
Examples of when phantom networks could constitute fraud include:
- An insurance sales representative falsely assures a self-insured employer that top orthopedic surgeons in the area participate in their narrow network plan, only for employees to later find out most of these “in-network” orthopedic groups had withdrawn from the health plan network before the contract was finalized.
- A managed Medicaid provider fails to inform the contracted managed care organization in their state that they are not accepting new patients, making it challenging for Medicaid patients to find a provider that will help them with their health. The provider could be paid on a value based care contract inaccurately.
While outdated provider data alone may not constitute fraud, intentionally publishing inaccurate data to mislead customers into purchasing plans they otherwise would not have purchased, could be considered healthcare fraud. Neglecting to address ongoing provider data issues and failing to notify members when providers leave the network, retire, or relocate can be viewed as negligence and misleading conduct.
Legislation and Efforts:
Despite the recent “No Surprise Act” legislation, inaccurate provider directory data remains a significant issue, as highlighted in an article by Healthcare Dive. Efforts such as the recent CMS Request for Information aim to gather data-related insights about provider directory data, networks, and other elements that impact payments in the Medicare Advantage system. These initiatives, along with various state and federal efforts, are designed to prevent unexpected healthcare costs and maintain accurate provider directories.
The Solution:
Upgrading outdated technology is crucial to solving this problem and rebuilding trust with American healthcare consumers. This includes reducing the exorbitant administrative costs associated with provider onboarding, credentialing, contracting, and ongoing provider data management. Implementing new automated systems for tracking and managing provider data, along with real-time comparison technologies, enables health plans to streamline workflows, automatically update information, and alert members promptly about changes such as providers leaving the network, relocating, retiring, or facing licensing issues.
The call to action is clear—invest in modern technology to ensure accurate, real-time provider data. By doing so, we can protect healthcare consumers from unexpected costs and improve the overall efficiency and reliability of the healthcare system. It’s time to prioritize the well-being of those at the center of the issue—the people relying on healthcare services.
To learn more about how Virsys12 can help your healthcare organization with enterprise provider data management efforts, please contact us today.
View demos of our V12 Network and V12 Provider Data Network as well.
