Companies that administer private Medicare and Medicaid insurance plans inaccurately list many of the mental health professionals who can treat enrollees in those plans, a new report from a federal watchdog finds.
Investigators say some insurers effectively created “ghost networks” of psychologists, psychiatrists and other mental health professionals who allegedly agreed to treat patients covered by government-funded Medicare and Medicaid plans. In fact, investigators say many of these professionals are not under contract with these plans, do not work in the listed locations, or are retired.
The Department of Health and Human Services' Office of Inspector General, which oversees the giant health care programs Medicare and Medicaid, released its findings. in a recent report.
The report focuses on insurers that the government pays to cover people in Medicare Advantage plans and private Medicaid plans. About 30% of all Americans are covered by such insurance, the report says. The government pays insurers hundreds of billions of dollars each year.
Companies are paid a set rate per person they serve and are allowed to keep the money they don't spend on patient care. Insurers must have a sufficient number of contracted health care providers to serve patients in each region they cover.
But a new report found that 55% of mental health professionals included in the Medicare Advantage plan network did not provide such care to anyone in the plan. For Medicaid managed care plans, the figure was 28%.
Some mental health professionals told investigators they should not have been included in the list of health care providers for insurers' members because they no longer worked in the listed locations or because they were not enrolled in Medicare Advantage or Medicaid managed care plans. Others said they work as administrators and are no longer involved in patient care.
In one case, the report said, a private Medicaid plan listed a mental health professional providing care at 19 practice locations. But when investigators checked, the administrator of one of the clinics said that this man had retired several years ago.
Janine Simpkins of Mesa, Arizona, learned how thin networks can be when a 40-year-old family member found herself in crisis this fall. Simpkins struggled to find a drug rehab program that would accept the Medicare Advantage insurance a relative is on because of a disability.
Simpkins said she contacted about 20 rehabilitation programs, none of which participated in the Medicare insurance plan. “You feel like you’ve fallen,” she said. “I was really surprised because I thought we had something good for her.”
Simpkins' relative ended up being admitted part-time to the hospital instead of an inpatient rehabilitation center.
It can be difficult for patients to find timely and nearby help for a variety of health problems, from the common cold to cancer.
But Jody Nudelman, the regional inspector general who helped write the federal report, said in an interview that the stakes may be especially high for patients seeking mental health care.
“They can be especially vulnerable,” she said. It can be difficult for people to admit they need that help, and any obstacle can discourage them from seeking help, she said.
She added that taxpayers will not get their money's worth if insurers fail to meet their obligations to provide sufficient care options for Medicare and Medicaid enrollees.
The federal report focused on a sample of 10 counties in five states: Arizona, Iowa, Ohio, Oregon and Tennessee. It included urban and rural areas. He did not name the insurers whose networks were checked.
Susan Reilly, vice president of public affairs for the Better Medicare Alliance, a trade group representing Medicare Advantage plans, said managed care companies support federal efforts to improve access to mental health services. “While this report examines a small sample of plans, we agree there is more work to be done and are committed to continuing this progress with policymakers,” she said in a statement.
The report's authors said their sample represented the situation in the country well. Forty Medicare Advantage plans and 20 Medicaid managed care plans were reviewed.
The report recommends that government administrators more frequently use medical billing data to confirm whether in-network providers are providing care to patients covered by private Medicare and Medicaid insurance plans.
Observers also recommend that federal regulators create a nationwide, searchable directory of mental health providers that lists the Medicare and Medicaid insurance plans that each accepts. They say such a directory will help patients find help and make it easier to double-check the accuracy of network provider listings.
Federal administrators overseeing the Medicare and Medicaid programs have taken steps to create such a guide, the authors said. Reilly, the industry spokesman, said managed care companies support the effort.
