It’s hard to know if your health insurance plan is as good as advertised. You pay a monthly premium to access a network of health providers. But call the numbers in your provider directory, and you’re bound to find ones who can’t — or won’t — see you.
These errors are at the heart of a ghost network. Some providers have moved, retired or even died; others left insurance networks because of low pay and intense scrutiny. Even though these providers no longer accept your insurance, their names may remain in the directory. When that happens, policyholders are left to believe that the plan has more options than actually exist.
“Any inaccuracy constitutes a ghost network,” said Abigail Burman, a consumer protection attorney who studies provider directory errors. “This is basic information. It needs to be right.”
Insurers’ failures to correct these errors have led to dire consequences for people seeking mental health care, as demonstrated by a recent ProPublica investigation of one man’s months of struggle to access treatment. Because of the widespread nature of ghost networks, some policyholders are more likely to pay out-of-network costs and face a greater chance of treatment delays — if they get treatment at all.
ProPublica spoke with experts, clinicians and advocates to understand the challenges posed by provider directory errors. They all suggested specific ways for policyholders to navigate a ghost network.
How much do insurers know about the errors in their directories? And what are they required to do about it?
Insurers have acknowledged the problem and in some cases have vowed to address it. AHIP, a national association of health insurers, said in a 2023 statement to the U.S. Senate Committee on Finance that insurers update provider directories through “regular phone calls, emails, online reminders, and in-person visits.” However, AHIP wrote that insurers can’t always quickly fix errors because providers sometimes fail to keep their own professional information up to date. (AHIP declined ProPublica’s request for an interview.)
But Dr. Robert Trestman, a Virginia psychiatrist who testified about ghost networks to the same committee, told ProPublica that insurers are able to track “every detail of finance” around things such as billing and coding. Because of that, he said, insurers’ failures “to set up a system for keeping track of who is in network or not is on them.”
But insurers haven’t had to make it a priority. Simon Haeder, a Texas A&M University professor who studies ghost networks, said that insurers have “very little incentive” to closely monitor directories. Unless tougher regulations are passed, he said, policyholders will continue to struggle with directories full of “inconsistent, outdated or incomplete data.”
For years, it has fallen to academic researchers and secret shopper surveys to reveal the pervasiveness of these errors. Lawmakers have passed bills and called for further reforms. In spite of that, the errors still plague policyholders.
I’m shopping for a plan. How do I know if it is as good as advertised?
Do your homework. In the absence of the insurer making it a priority to update its directory, the task of checking its accuracy falls to you. You can head to the website of the insurer whose health plan you’re interested in buying. Find the provider portal. Since an insurer may offer different networks for each plan, experts suggest double-checking that you’re only searching for providers available in the network that you want.
If you already have a provider, type in their name to see if that person is listed in-network. If you don’t have one, find a provider that’s listed as being in network and taking new patients, and who seems to meet your needs. From there, experts encourage reaching out directly to the provider to verify that both of those things are true.
“Verify, verify, verify,” said Dr. Jane Zhu, an associate professor at Oregon Health & Science University’s medical school who studies ghost networks. “Accuracy in behavioral health provider directories is akin to a coin flip.”
I already have a health plan. What should I do?
Don’t worry if you’ve paid for a plan or have one through your employer. There are other ways to minimize the perils of provider directory errors.
But experts say that you’ll need to arm yourself with some facts.
Track down your “Evidence of Coverage.” The document, which is typically about 100 pages long, outlines what your insurer must do to fulfill its contractual obligations. For instance, if you can’t access an in-network mental health provider within a certain period of time, the insurer may be on the hook for tracking down an out-of-network provider.
From there, you can call the insurer to find out if it handles your mental health benefits or if it has outsourced management of them. If those benefits are “carved out” from your plan, you may have to seek answers about provider directory errors from that subcontractor. (Should you encounter any errors in your directory, this information could come in handy.)
Experts say that by getting these answers, you’ll be able to better fight for your rights.
What should I do if I encounter provider directory errors?
Health care experts warn that you’re likely to encounter errors in your provider directory. They advise not to become discouraged when you do.
David Lloyd, chief policy officer with the mental health advocacy group Inseparable, suggests taking notes of the calls to providers. Did they answer the phone? Did they say they accept your plan? Do they see new patients? You can write all your notes down in this handy worksheet created by Cover My Mental Health, an Illinois-based consumer advocacy group. Take photos of the directory errors, too.
How many calls should I be expected to make?
Some policyholders have called at least 50 supposedly in-network providers in pursuit of an appointment. But experts say you shouldn’t have to contact that many. Burman suggests making a “reasonable effort.” To her, that means making five to 10 calls to providers listed in-network.
She and others note that if you’re in distress because of your mental health, you don’t have to call on your own.
“Ask a friend or family member for assistance and to help advocate for you,” said Wendell Potter, a former Cigna vice president who is now a consumer advocate.
None of my calls secured an appointment. What should I do now?
If you’ve made that reasonable effort and haven’t managed to lock down a provider, experts recommend making another call to your insurer. Inform the customer service rep that you couldn’t make an appointment with a listed provider despite multiple attempts. Request that the rep schedule an appointment for you. Then ask for the rep’s email address and put the request in writing — and ask the rep to reply the same way.
Meiram Bendat, a lawyer and psychotherapist in California, suggests reminding insurers that they “must share in the responsibility of identifying timely and geographically accessible providers.” The exact regulations depend on where you live and the kind of plan you have, so some research may be required before the call. In some instances, you can ask for a care manager and the insurer will assign an employee who can help secure a mental health appointment.
“Set the expectation that the customer service rep needs to solve this problem,” said Joe Feldman, founder of Cover My Mental Health.
If the rep doesn’t connect you with a provider, health insurance experts recommend asking the rep to file an administrative grievance. Persistence is key, Burman said. Be assertive. Demand the grievance be addressed — or escalated to a manager who will resolve your concern.
“Don’t feel like you’re the problem,” Burman said. “They are the problem for engaging in deceptive practices.”
My ghost network grievance hasn’t been resolved. Now what?
While waiting for your insurer to act, health insurance experts also encourage reaching out to your insurance regulator.
Finding that regulator can be a tricky task given America’s complex patchwork of insurance regulations. You’ll need to determine which government agency oversees your insurer. While more research is required to see who will be able help, experts point to the following agencies as a starting point:
- If you purchased a plan from your state’s Health Insurance Marketplace, or have a fully insured plan through your private employer, you can get in touch with your state’s insurance department.
- If you have a Medicaid plan, you can contact your state’s Medicaid agency.
- If you are enrolled in Medicare, you can reach out to the Centers for Medicare & Medicaid Services.
- If you have a self-funded plan from your private employer or a health and welfare benefit plan from your union, you can try the U.S. Department of Labor’s Employee Benefits Security Administration.
Once you find the right agency, experts suggest that you prepare your complaint. You don’t have to write a new one from scratch. Gather information from your grievance, along with any other new developments, and submit that to the regulator.
Is there anything else I can do?
Yes, there are a few other ways. Whatever approach you take, Potter urges you to make noise, as if you are “a relentless squeaky wheel.”
If you are covered through an employer’s health plan, see if your human resources department can help talk to the insurer.
Or contact the constituency service offices of your federal and state elected lawmakers. They might be able to directly reach out, too.
Depending on where you live, there may even be legal services or consumer advocacy agencies that can help out as well.
“As a consumer, your superpower is not going away,” Burman said. “Your strongest weapon, in the face of a company that wants you to go away, is to not go away.”
