Addressing 'Ghost' Networks in Medicare Advantage and Medicaid Managed Care

Recent investigations highlight the issue of "ghost" networks in publicly funded but privately run healthcare plans such as Medicare Advantage and Medicaid managed care, which cover over 100 million Americans. These ghost networks refer to providers listed as in-network who are actually unavailable, moved, or not accepting new patients, challenging network adequacy, essential for patient access to care. Analysis by The Wall Street Journal across 22 states found over one third of doctors listed in Medicaid managed care networks did not provide care in 2023, with Centene, a major insurer, exemplifying the issue by listing child psychiatrists who largely did not see Medicaid patients, despite substantial profits. Academic research on Medicare Advantage networks reveals that about 40% of listed providers billed fewer than 11 patients, indicating many likely ghost providers, with a disproportionate effect on beneficiaries in financially distressed communities. Despite CMS regulations specifying network adequacy standards for geographic accessibility and provider ratios, enforcement has been minimal, with only a few warning letters issued between 2016-2022 and no sanctions enforced as of 2024. Medicare Advantage networks often include under half the providers that accept traditional Medicare, suggesting a need for stricter adequacy standards and improved directory accuracy to uphold plan viability. A forthcoming CMS requirement starting in 2027 for Medicare Advantage plans to submit provider directory data may enhance transparency and enforcement capabilities. Strengthened regulations and rigorous oversight are key to ensuring patients have reliable access to adequate provider networks within managed care systems.