Photo: Baraka Gurbuz Derman
Many Medicare Advantage and Medicaid managed care plans have limited networks of behavioral care providers, necessitating steps to improve the accuracy of network directories, according to a new report from the Department of Health and Human Services’ Office of the Inspector General.
Limiting these provider networks further is the inclusion of inactive providers who don't provide any of these services to enrollees, OIG found.
According to the agency, most of these inactive providers should not be listed as network providers by the plan. For example, in some cases these providers no longer work at the locations listed by the plan, or they've indicated they would not see patients enrolled in the plan.
These inactive providers are sometimes referred to as “ghost” providers and can make the networks appear larger than they are, said OIG.
WHAT'S THE IMPACT
The agency said it conducted the review because most Medicare and Medicaid enrollees’ behavioral healthcare is covered by managed care plans, meaning enrollees’ access to providers is largely determined by the network of providers contracted by each plan.
Plans are required to provide all enrollees with a list of providers in their network – a network directory.
When a network has less than 25% of an area's workforce, it's considered a limited network, said OIG. The breadth of a network is an important measure of access for providers.
Three-quarters of the Medicare Advantage plans under review had less than 25% of the county's behavioral healthcare workforce in their networks. In Medicaid, half of all plans fit that description.
That means enrollees in those plans may not have access to 75% or more of the behavioral healthcare providers in their counties because those providers were not included in their plans’ networks. Medicare Advantage plans included a smaller percentage of the behavioral healthcare workforce than Medicaid plans.
And in more than half of Medicare Advantage plans and a third of Medicaid plans, at least one-third of the providers listed in their networks were inactive. This suggests significant inaccuracies in the plan's directory, OIG said.
In Medicare Advantage, on average, 55% of behavioral healthcare providers listed in plans' networks did not provide a single service to enrollees in 2023. In Medicaid, about 28% of providers did not provide a single service.
In OIG's estimation, almost three-quarters of inactive providers should not have been listed as network providers. Almost half did not work at any of the locations listed in the network directory, about one-fifth did not accept patients with their managed care plan, and some inactive providers didn't see patients because they served in administrative roles.
OIG recommends that the Centers for Medicare and Medicaid Services use data to monitor provider networks and take additional steps to improve their accuracy.
It also wants CMS to explore how a nationwide directory could reduce inaccuracies and increase administrative efficiencies for providers and patients.
THE LARGER TREND
The Medicare Advantage program has undergone significant policy changes during the past year, affecting deductibles, out-of-pocket costs, provider networks and prior authorization determinations.
These changes have contributed to increased confusion, lower member satisfaction and a widespread lack of trust among Medicare Advantage plan members, according to the J.D. Power 2025 U.S. Medicare Advantage Study.
Overall customer satisfaction with Medicare Advantage plans is 623 (on a 1,000-point scale), down 29 points from a year ago. The primary cause of this decline in customer satisfaction, said analysts, is a 39-point drop in members’ overall level of trust in their Medicare Advantage plan.
Products and coverage, and ease of doing business were other metrics that are on the decline.