Managed care organizations (MCOs) are also called “Medicaid management companies.” These companies are responsible for creating healthcare and mental health provider networks to serve their members. They publish directories that list all the providers in their network. However, members, providers, and auditors have discovered that many providers listed in these directories are unavailable to serve the members.
“Ghost” and “phantom networks” describe directories maintained by managed care organizations, listing healthcare providers purportedly available for their members. However, these networks often include providers who never provided care – or no longer do so – for the plan’s members.
The reasons vary and are all bad for patients. Many of the listed “phantom” providers might not be accepting new patients, severely limit the number of Medicaid patients they see due to low payment rates, no longer participate in the insurance plan, may have moved or retired, or may have been included in a directory without their knowledge. As a result, patients can find it challenging to access care, even though it appears on paper that numerous providers are available.
The dangers of these fictitious networks are that they can lead to delays in care as patients try to find an available provider, and patients grow frustrated or lose trust in their insurance company or managed care organization. Compounding the harm to patients, there may also be additional financial costs if patients who cannot find a provider in their network seek out-of-network care at higher out-of-pocket costs.
Why does this matter for Louisiana’s children?
Our Methodist Aftercare Services staff assist children and families long after a child returns home from intensive residential care. One of their tasks is to connect families to resources in their home communities to assist the family as the child transitions back into the family, school, and community. We work with the family to create a local support system that includes medical and mental health services.
Our Methodist Aftercare Services staff find that many of the providers listed in the Healthy Louisiana MCO directories are ghosts. They may answer the phone, but they no longer accept Medicaid, limit the number of MCO members on their caseload, or don’t know why they are in the directory.
When services are unavailable for children and parents, it is easy for minor crises to become large and result in the child being readmitted to residential care or removed from the family. Louisiana’s ghost networks have got to go.
Ghost networks raise legitimate concerns about the transparency and integrity of managed care organizations. Patients deserve accurate, up-to-date provider directories. Many states have legislation that requires accuracy, but without enforcement, the legislation does not benefit citizens.
Understanding Mental Health ‘Ghost’ Networks provides links to public testimony submitted to the Senate Finance Committee in May of 2023.
“Laws were passed in California, Louisiana and Maryland requiring accurate directories, but the problems continued despite the legislation. The researcher studying these efforts concluded that the lack of progress was directly related to weak enforcement mechanisms, minimal penalties, and the lack of critical tools to improve compliance.” (Mary Giliberti, JD Chief Public Policy Officer Mental Health America Before The United States Senate Finance Committee Hearing: “Barriers to Mental Health Care: Improving Provider Directory Accuracy to Reduce the Prevalence of Ghost Networks” on May 3, 2023)
Read more at: Louisiana’s Ghost and Phantom Networks Have Got to Go