Many Medicare Advantage and Medicaid Managed Care Plans Have Limited Behavioral Health Provider Networks and Inactive Providers

Report Materials

• Full Report(PDF, 3.2 MB)
• Report Highlights(PDF, 391.3 KB)

Why OIG Did This Review

• Medicare and Medicaid play significant roles in ensuring access to care for millions of enrollees with behavioral health conditions, which include mental health disorders and substance use disorders.
• Most Medicare and Medicaid enrollees' behavioral health care is covered by managed care plans. As a result, enrollees' access to providers is largely determined by the network of providers contracted by each plan.
• Plans must provide enrollees with a list of all providers in their network, i.e., a network directory. This review assessed the extent to which selected plan networks were limited and whether the providers listed in each directory were actively providing services to the plan's enrollees.

What OIG Found

• Many Medicare Advantage and Medicaid managed care plans had limited networks of behavioral health providers.
• These provider networks were further limited by including inactive providers who did not provide any services to enrollees.
• Most of these inactive providers should not have been listed as network providers by the plan. For example, these providers no longer worked at any of the locations listed by the plan or they indicated they would not see patients enrolled in the plan.
  • These inactive providers are sometimes referred to as "ghost" providers and can make the networks appear larger than they are.
• Providers cited administrative burden and low payment rates as factors affecting their willingness to work with managed care plans.

What OIG Recommends

1. Use data to monitor provider networks and take additional steps to improve the accuracy of network directories in Medicare Advantage.
2. Work with States to improve the accuracy of network directories in Medicaid managed care.
3. Continue exploring how a nationwide directory could reduce inaccuracies and increase administrative efficiencies for providers and patients.

CMS did not explicitly concur or nonconcur with our recommendations; however, it indicated that it has taken a number of steps that are aligned with each of the three recommendations and that additional steps are planned.