“Ghost networks” abound in Medicare Advantage and Medicaid, research shows

The problem of “ghost” networks—when doctors are listed as being in-network for managed care plans, but turn out not to be available—is starting to get more attention. Here’s what you need to know from recent research and reporting on the topic.

Although commercial insurance plans can have “ghost” providers, recent reports have focused on plans that are publicly regulated. More than 100 million Americans are covered by healthcare plans that are publicly funded but privately run (34 million through Medicare Advantage and 72 million through Medicaid managed care). These plans theoretically save the government money by contracting with certain providers to create networks, and then coordinating care across these networks to monitor cost and quality. 

The success of these plans depends on whether there are enough doctors in the network to serve the needs of plan beneficiaries, also known as “network adequacy.” Recent research and investigations have found that plans often list providers under contract who are not actually available to see patients. Sometimes the provider information is incorrect, they have moved, or they aren’t seeing new patients. Either way, having so many so-called “ghost networks” makes it hard for patients to access the care they need. 

The Wall Street Journal digs in

To better understand the scope of the problem, The Wall Street Journal dug into the records of major Medicaid Managed Care providers across 22 states. They discovered that more than one third of the doctors listed in the networks didn’t provide care to Medicaid patients in 2023. 

For example, Centene—an insurance giant providing health services in all 50 US states—claimed to have 28 child psychiatrists available to Medicaid patients within 50 miles of a suburb of St. Louis, Missouri. But upon investigation of Medicaid claims records, the Journal found that eleven of these practices saw zero Medicaid patients that year and nine saw 10 or fewer such patients. At the same time, Centene has been raking in the profits, collecting $84 billion from Medicaid in 2024 despite providing questionable coverage.

“It’s a fake system,” said Elisha Yaghmai, a Kansas doctor who runs a company that provides physicians to rural hospitals, in The Wall Street Journal. “It doesn’t actually get them care.”

How many “ghosts” are in Medicare Advantage? 

Research by Dr. Mika Hamer at the University of Maryland School of Public Health showed how pervasive ghost networks may be in Medicare Advantage. Her team is analyzing national Medicare Advantage Enrollment and Encounter files and comprehensive provider network data from tech company Ideon from 2019-2022. 

Of the 432,146 providers who were advertised as “in-network” in one or more of the 3,659 Medicare Advantage plans nationwide in this data set, her preliminary results presented at the Association for Public Policy Analysis and Management fall conference showed that nearly 40% of these providers were likely “ghosts,” having billed fewer than 11 total Medicare Advantage beneficiaries in that network. Perhaps unsurprisingly, those plans that had a higher degree of ghost networks tended to have enrollees who came from financially distressed communities. 

Who’s busting ghost networks? Not CMS…

Government agencies could be doing much more when it comes to tracking ghost networks. CMS has regulations for network adequacy that specify how many providers plans must have in each network and how accessible providers must be, based on the type of region and specialty. For example, in a large metropolitan county, a network should have at least 1.67 primary care providers per 1,000 beneficiaries, and 90% of beneficiaries in the county must be able to access at least one primary care provider within five miles.  

However, an inquiry by KFF Health News found that these rules seldom result in enforcement actions. From 2016-2022, CMS sent letters to only five insurers after one or more of their plans failed to meet provider network adequacy requirements. This small number reflects “the outcomes of targeted reviews, not a comprehensive audit of all plans in all years,” CMS spokesperson Catherine Howden told KFF Health News. 

Most of the network violations described by KFF were due to plans not having enough providers under contract listed in their directory, rather than their provider directories not being accurate. Three letters required a “corrective action plan” from insurers, warning that their plan could be fined or suspended if no actions were taken. While some plans voluntarily exited the market after receiving a letter, CMS had not imposed any sanctions on health plans for network adequacy failures as of 2024.

Policy changes for better access

It’s clear that current network adequacy standards and enforcement aren’t doing the job. A recent report from KFF found that overall, Medicare Advantage plans include just 48% of the doctors that accept traditional Medicare in their provider directories. If we want Medicare Advantage to be a viable alternative to traditional Medicare, policymakers should raise the network adequacy standards to increase the number of providers in Medicare Advantage networks, and monitor these directories for accuracy.   

There is one encouraging change on the horizon. Starting in 2027, Medicare Advantage plans will be required to submit their provider directory information to CMS, which they may be able to publish in a format that is much easier to understand and compare than information currently on insurance plan websites. With better access to provider directory data, CMS should be empowered to audit more plans and take stronger enforcement actions when provider lists are inaccurate and networks are too narrow. 

If all patients are to get the care they need, it is clear that we as a nation need adequate numbers of providers in care delivery networks– and regulations promoting that need to be stricter and better enforced.