Congress, Bad Data, and Ghost Networks

Updated on November 28, 2023
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The Senate Finance Committee has advanced legislation that aims to eradicate ghost networks, a goal that will benefit payers, providers, and patients alike. 

As the legislation advances through the halls of Congress, all stakeholders must have a clear understanding of why the bill is necessary and what’s behind all those ghosts anyway.

Ghost networks are provider networks that appear robust and full of available providers but actually contain inaccurate data and, in reality, have limited availability and unreachable providers. These “ghosts” are no longer practicing, not accepting new patients, are not in-network, or have errors in their contact information. 

While the provider directory may look more than adequate, the gaps that exist make it challenging for the patient to even contact a provider, much less successfully make an appointment. To the people who matter most—the patients—big chunks of the directory are unhelpful.

Ghost networks are not a new phenomenon. A Yale Law & Policy Review completed in 2021 titled Laying Ghost Networks to Rest: Combatting Deceptive Health Plan Provider Directories declared “…these directories are deeply flawed.”

“[Ghost networks are a] pervasive issue in the American health care system. A three-phase study of the accuracy of Medicare Advantage directories, which included over 15,000 providers, found that between forty-five and fifty-two percent of provider directory listings had errors, with some individual plans having error rates as high as ninety-eight percent.”

These ghost networks create harmful barriers to care which keep patients sicker and prevent them from accessing the providers that can make them better. This is especially true in cases of patients seeking behavioral health care which was the driving force behind the provisions of the Senate bill addressing the imperative of accurate provider data.

Why is it so hard to get provider directory data right?

To understand how we got here, it’s critical to understand why getting this data right is such a challenge.

Managing provider data is a heavily manual process with rapidly changing inputs and no single source of truth. One may think that state boards, available claims data, and databases such as NPPES can be easily extracted and sorted for current and accurate data. But it’s not that simple. 

While those types of directories may be helpful and accurate for one or two data fields, such as secondary specialty, they are often inaccurate on some basic demographic data such as contact information. 

To compound the problem, once an inaccurate piece of data is repeated on different databases, the simple frequency of its appearance gives it the air of truth. It is inaccurate starting at the source and the inaccuracy is repeated in downstream directories. And once it’s metastasized in the system, it’s all the more challenging to root out.

Attestation is not the answer

Attestation, the requirement of having clinicians verify and update their data with payer directories, is a case of misaligned incentives. Up to 30 percent of physicians are unresponsive to attestation requests, simply because their workloads have them (rightly) focusing on their patients and they have no incentive to correct or update directory data.

That, compounded with the high degree of human error inherent with such a manual process renders attestation a poor solution to ensuring accurate and up-to-date directories.

How does the REAL Health Providers Act tackle the issue of ghost networks?

The Senate bill aims to combat the ghost network problem by, among other things, requiring Medicare Advantage (MA) health plans (beginning with plan year 2026) to verify their provider directory data every 90 days and, if necessary, update that information.

  • If a health plan cannot verify the data, the plan must indicate in its directory that the information may not be up to date.
  • A health plan must also remove a provider within 5 business days if the provider is no longer participating in the plan’s network.
  • If ​​a patient obtains 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.

The legislation also requires MA health plans to analyze the accuracy of their provider data on an annual basis and submit a report to HHS/CMS with the results of that analysis. HHS/CMS will use this information to publish accuracy scores for each plan’s provider directory.

While the bill lays out the requirements for MA plans related to data accuracy and upkeep, it does not dictate the “how.” Assuming the bill continues to advance with bipartisan support, and ultimately becomes law, MA plan sponsors will be left to figure it out. That’s where data partners with proven and guaranteed solutions for provider data accuracy come into the picture. 

The right data partner will both leverage the power of machine learning and be mindful of current and future U.S. legislative requirements. 

MA plans will need a partner who can do two things very well. First, they have to be able to identify the “ghosts” and then fill those resulting network gaps with real-life providers.

Only then will the directories be safe from the ghosts that haunt them.

Meghan Gaffney headshot copy
Meghan Gaffney

Meghan Gaffney is the CEO and co-founder of Veda, a company that brings science and imagination together to modernize ​healthcare with human-in-the-loop smart automation. Veda saves healthcare companies millions and makes it easier for patients to access care.​Meghan has over 15 years of experience working with elected officials and mission-driven organizations, as well as consulting on technology opportunities. She is a passionate advocate for artificial intelligence and machine learning and believes these technologies will create unprecedented economic opportunity for the United States and the world.