How to Avoid the ‘Ghost Network’ Issue in Your Health Plans

For your group health plan enrollees, finding a doctor who accepts their plan should be straightforward since each plan typically has a network of physicians available for enrollees.

However, enrollees regularly learn that a doctor that is clearly listed in their health plan’s provider list is no longer in their insurance company’s network, which can result in delayed or denied care as well as higher out-of-pocket costs. Welcome to the problem of health plan “ghost networks,” or “ghost providers,” which are usually the result of outdated provider lists.

This problem can result in employee resentment about their group health plan and saddle them with higher costs if they are forced to go out of network to seek out care. Here’s what your employees need to know if they encounter a ghost provider and are unable to access a certain medical service.

What are ghost networks?

A ghost network occurs when a health plan lists health care providers in its directory who are not actually available to enrollees. These providers may have:

• Retired or relocated without their listings being updated.
• Stopped accepting your health plan.
• Reached patient capacity and are not taking new appointments.
• Outdated contact information that prevents enrollees from reaching them.

Many insurer health plan directories are outdated. A 2023 report from the Office of Inspector General found that despite a Centers for Medicare & Medicaid Services rule requiring insurers to update their directories every 90 days, errors persisted. Some incorrect listings had remained on the network list for over a year.

Health plan enrollees who rely on inaccurate provider directories may experience:

• Delays in care: Finding an in-network provider can take weeks or even months, potentially delaying necessary medical treatment.
• Unexpected costs: Beneficiaries who unknowingly visit an out-of-network provider may face high out-of-pocket expenses or denied claims.
• Frustration and confusion: Patients may have to call multiple providers, only to be told that the doctor they are trying to see does not accept their plan.

What you can do

To help your staff avoid ghost networks, train them about the importance of veryifying information provided by their insurance company. This includes checking the provider’s acceptance of new patients, their willingness to see you and ensuring they are truly in-network for your specific plan.

They can do this by contacting the provider directly and verifying their network status and patient acceptance.

Before seeing a new doctor or specialist and to ensure that they are not charged for going out of network, health plan enrollees can start by verifying provider information by:

• Accessing the provider portal:   Use the insurer’s website to access their provider portal and search for specific providers you’re interested in.
• Directly contact the insurer: Contact the provider directly (phone, e-mail or online contact form) to confirm their willingness to accept new patients and their in-network status for your plan.
• Consult the provider directory: Double-check the accuracy of the insurer’s provider directory by verifying information like office locations, phone numbers, and acceptance of new patients.

If a health plan enrollee is confronted with an inaccurate listing, they can:

• Inform the insurer and request that it be corrected.
• File a grievance. If an enrollee is unable to make an appointment with a doctor listed as an in-network provider, they can ask the insurance company to help you schedule an appointment or file a grievance.