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Perspectives for Payers on Tackling Ghost Networks

Perspectives for Payers on Tackling Ghost Networks

MedCity News – Lawmakers have ghost networks in their sights, and payers can prepare now for policy changes.

It’s not uncommon for a patient, when searching their insurer’s provider directory, to find listings for physicians who are no longer practicing and no longer in-network, as well as inaccurate addresses, phone numbers, and websites. These phantom entries create “ghost networks” in health insurance.

For more than a year ghost networks have made headlines as an increasingly serious issue for payers, providers, and especially patients. Riddled with inaccurate data, these networks often lead to delayed care and surprise bills, significantly impacting member experiences and trust.

Frustrated patients have been contacting their elected officials to address the ubiquity of ghost networks. Legislators have been hearing from constituents that this problem is impacting patients’ lives and ability to get care–and they are doing something about it. Three bills–two in the Senate, and one in the House–have been proposed that specifically address inaccuracies in health insurance provider directories, with more stringent guidelines, tighter timeframes, published scores, and possible fines if providers fail to keep their directories compliant.

Payers have good reason to prepare for any regulation changes now as the traditional means of checking directory accuracy–call campaigns, attestations, or manual roster intake–are cumbersome and costly processes that have not proven effective.

What is proven? Automated solutions to meet the implementation windows and level of accuracy these new bills propose.

Machine learning models look at all of this information and can accurately predict the right answer to a higher degree of accuracy than manual outreach and other traditional methods of attestation.

Policy reform initiatives

Three recent legislative efforts are aimed at addressing the root causes of ghost networks and enhancing healthcare access for patients.

U.S. Senators Michael Bennet (D-CO), Thom Tillis (R-NC), and Ron Wyden (D-OR) introduced the REAL Health Providers Act in October 2023. The bipartisan-supported bill is backed by the Senate Finance Committee and aims to ensure that Medicare Advantage plans keep accurate directories and protect their members–most of them seniors–from receiving surprise medical bills.

The House version of the REAL Health Providers Act – H.R. 7708 – was introduced in March 2024 by Representatives Greg Murphy (NC-03)  and Jimmy Panetta (CA-19), among others. It mirrors the language in the Senate bill and aims to protect seniors from delayed care and unnecessary costs.

Read the full article from Meghan Gaffney on MedCity News



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