The Office of Inspector General (OIG) found that almost three-quarters of inactive behavioral health providers should not have been listed in the networks of Medicare Advantage and Medicaid Managed Care plans.
A new OIG report exposes the shortfalls in Medicare Advantage and Medicaid Managed Care plans’ network directories .
The watchdog said it conducted the review to assess whether selected plan networks were limited and whether psychiatrists, psychologists, and clinical social workers listed in each directory were actively providing services to the plan’s enrollees.
OIG based the review on provider network lists, behavioral health workforce information from state licensing boards, Medicare Advantage and Medicaid encounter data, and a survey of inactive providers. Investigators then focused on 40 Medicare Advantage plans and 20 Medicaid managed care plans in 10 counties (five urban and five rural from five states geographically dispersed throughout the country.
Key findings
The OIG uncovered several access gaps, including:
Limited networks: Three-quarters of the Medicare Advantage plans had less than 25 percent of the counties’ behavioral health workforce in their networks. Almost half of the Medicaid plans had less than 25 percent of the counties’ workforce in their networks.
“This means that enrollees in these plans may not have had access to 75 percent or more of the behavioral health providers in their counties because these providers were not included in their plans’ networks,” OIG said in the report.
Inactive providers listed: Many managed care plans had a high percentage of inactive providers in their networks who did not provide services to enrollees. This means they did not provide a single service to the plan’s enrollees in 2023.
In more than half of the Medicare Advantage plans and a third of the Medicaid plans, at least one-third of the providers listed in their networks were inactive. Furthermore, the OIG said a high percentage of inactive providers may indicate that there are significant inaccuracies in the plan’s directory.
Ghost networks: The OIG surveyed a random sample of inactive providers in Medicare Advantage and Medicaid plans to better understand why providers were not providing services to enrollees and whether they should be listed in plans’ networks. The watchdog found that almost three-quarters of inactive providers should not have been listed as network providers. In most cases, the providers no longer worked at any locations listed by the plan. In other instances, providers indicated they would not have seen patients enrolled in the plan or never signed up to be a network provider with the plan.
OIG said that a high percentage of providers who should not have been listed as network providers may be an indication of “ghost networks,” which can pose a significant barrier to enrollees seeking behavioral health care.”
Administrative burden, low reimbursement factors behind limited networks: Many providers said they aren’t willing to work with managed care plans because of paperwork and pay. One-fifth of inactive providers complained about administrative hurdles, such as complex billing, enrollment procedures, or any other tasks other than direct clinical services that managed care organizations require, such as prior authorizations. Fourteen percent of inactive providers expressed concern about low payment rates.
OIG recommendations
Although Congress and the Centers for Medicare & Medicaid Services (CMS) have taken steps to improve the accuracy of network directories and access to behavioral health providers, the OIG also recommends CMS:
- Use encounter data to identify inactive providers listed in a Medicare Advantage plan’s network directory
- Work with states to improve the accuracy of network directories in Medicaid managed care
- Explore how a nationwide directory could reduce inaccuracies and increase administrative efficiencies for providers and patients
The watchdog said that CMS did not explicitly concur or nonconcur with its recommendations; however, the agency indicated that it has taken a number of steps that are aligned with each of the three recommendations and is planning to take additional steps.