Ghost networks have become a costly and persistent challenge for health plans. These inaccurate healthcare provider directories include clinicians who are no longer in-network, not accepting new patients, or are listed with outdated locations, names or specialties, leading to a disjointed member experience, operational inefficiencies and heightened regulatory scrutiny.
Maintaining up-to-date provider data is not just a compliance issue, it’s a strategic move that impacts Consumer Assessment of Healthcare Providers & Systems (CAHPS) scores, Medicare Star Ratings and health plan member retention. With increasing oversite from state and federal regulatory bodies, the stakes for health plans have never been higher. To eliminate ghost networks effectively, health plans must move beyond inefficient methods for updating their directory to a proactive approach to data readiness.
What’s The Root Cause of Ghost Networks?
Many factors contribute to health plan ghost networks, including:
- Inconsistent Market Requirements: States and health plans each have their own data accuracy requirements. Different policies impact how often provider directories are updated. These variations can complicate attempts to maintain consistent data, as information for a specific state may not be lined up with that of the overall health plan. For example, if a state updates their database every 90 days, but the health plan does not update its provider directory accordingly, a member attempting to schedule care using the plan directory may run into issues confirming if a provider is or is not actively accepting new patients.
- Fragmented Ownership and Knowledge Gaps: If a health plan’s team is not working in a shared technology ecosystem, data may not be entered consistently. New job responsibilities, shifts in teams, and knowledge gaps can increase data inconsistencies resulting in delays or omissions in provider directories.
- Complex Cross-System Integration: Data for provider directories lives across many platforms and often is not in the same format. There are many systems at play to integrate provider data into a central repository. Bringing data together, controlling the formatting and synchronization, and version control can be challenging factors for health plans trying to maintain an updated database.
Pain Points & Government Action
The frustration associated with ghost networks is threefold. Health plan members experience the largest frustration, as they are left with an inaccurate list of providers and struggle to find someone in-network for their needs. Findings published in the Journal of the American Medical Association, reviewed physician directories from five large health insurers and found that 81% of entries had inconsistencies, such as address errors or the wrong specialty’s being listed for a physician. This can result in patients calling multiple offices trying to schedule care or mistakenly scheduling appointments with a provider who is not covered by their insurance. Providers themselves experience hindrances to their workflow, with phone lines tied up by members calling to try to schedule appointments, only to learn that they are working from an out-of-date list. For health plans, ghost networks can result in regulatory and financial stressors, as non-updated lists can lead to a decrease in quality scores. A government review of Medicare Advantage plans found that the share of inaccurately listed provider locations ranged from nearly 5% to 93%, depending on the directory. The cost associated with cleaning up ghost networks, the lost opportunity to effectively engage members in in-network care, heightened member dissatisfaction and member churn can lead to penalties, leaving health plans.
Under the No Surprises Act, members are protected against surprise medical bills and determining out-of-network provider payments. This provides an incentive for health plans to keep their provider directories up to date, as the lost revenue from not only having a member go out-of-network for care but also having to cover the difference between in- and out-of-network care can quickly add up. Additionally, plans are expected to verify and update their provider directories at least every 90 days, establish clear procedures for removing providers that they are unable to verify, and make updates to provider information within two business days of receiving it from a provider.
A Data Readiness Approach to Provider Accuracy
Addressing ghost networks requires more than cleaning up existing databases, it requires a comprehensive data strategy. Leading health plans are investing in technology platforms and processes that unify, verify, and maintain an accurate provider database through:
- Real-Time Identity Resolution: Advanced tools help payers merge existing data from disparate systems, resolving identity mismatches to create a single, accurate record for a provider.
- Stewardship and Automation: Ongoing data quality checks and new data integration are built in as a continuous process aligned with regulatory cadence (e.g. every 90 days).
- Flexible Deployment and Governance: Modern solutions offer flexible deployment (on-prem, private cloud, or hybrid), to help health plans meet HIPAA and HITRUST standards while maintaining customized infrastructure.
- Support for Merger & Acquisition and System Consolidation: As health plans grow or modernize, scalable platforms can consolidate provider information, maintain organizational hierarchies, and preserve data accuracy during transitions.
Ghost networks are a symptom of outdated, siloed infrastructure, and regulators are catching up. By adopting a holistic data readiness approach, health plans can strengthen member trust, reduce regulatory risk, and improve access to accurate provider information.
