OIG warns of ‘ghost network’ trouble in maternal health managed care

The U.S. Department of Health and Human Services’ Office of Inspector General (OIG) warns consumers about the existence of inaccurate Medicaid managed care provider directories that the agency said may negatively impact “overall maternal health outcomes” for patients all over the country if the issue is not addressed. 

Looking at the three largest private companies providing managed care services for state Medicaid programs—Centene, Elevance Health and UnitedHealthcare—the OIG discovered that directories meant to guide patients to care options included ineligible providers, such as those that are out-of-network or who will not accept payment from these plans. 

Known as “ghost networks,” this type of error can arise to the level of insurance fraud if found to be intentionally misleading. While authorities at the agency stopped short of accusing the insurers of a crime, the issue with inaccurate directories extended across all five states that it looked at for a new report. 

For this particular report, the OIG was looking exclusively at maternal health, as pregnancy is one of the primary reasons why patients opt to enroll in Medicaid. 

“Medicaid pays for over 40 percent of births and most pregnant Medicaid enrollees are in managed care plans,” the HHS watchdog wrote. “Access to timely and high-quality care is important to promote good maternal health outcomes. Receiving timely care throughout pregnancy and the postpartum period can help prevent maternal deaths and manage pregnancy and postpartum complications.”

It added that it “selected a sample of providers from network lists” that Centene, Elevance Health and UnitedHealthcare sent to states, in an effort to assess the quality of those directories. From there, the OIG said it looked up the providers in the online databases plans have for members to find services, trying to discover if what the insurers reported to the state matched the up-to-date information enrollees have access to. 

In some cases, they didn’t. To varying degrees, all three provider directories were inaccurate when it came to maternal health. Looking at its random sample, the OIG found that 22% of Centene providers were not in network. Similarly, 6% of those UnitedHealthcare listed were also not in network, with Elevance also failing 4% of the time. 

To make matters worse, the OIG found that the directories were incomplete. As many as 35% of in-network providers for the maternal health Medicaid plans were missing from Centene’s directory, followed by 25% for UnitedHealthcare and 11% for Elevance. 

Contact information in the directories sent to states was also inaccurate. Elevance lacked proper provider contacts 41% of the time, followed by Centene at 37%. UnitedHealthcare was found to contain inaccurate provider addresses or phone numbers 22% of the time. 

While incomplete lists and a lack of contact information are a problem, the OIG was particularly concerned with instances where providers were listed as in-network erroneously, as these create snags for new and expecting mothers seeking care, who may be left to discover last minute that services will be denied due to a lack of coverage eligibility. 

“‘Ghost providers’ can cause confusion and frustration for enrollees who use the online provider directories to find and contact in-network providers. Enrollees who contact these providers to seek care will not, in general, be able to receive insurance coverage for such care through their plan,” the agency wrote in its report. “This may delay access to maternal healthcare. Timely access to prenatal and postpartum care is critical for health outcomes, so delays in access to maternal health care are concerning.”

“In addition, some enrollees may select a Medicaid managed care plan on the basis of the providers who appear as in-network in the provider directory. ‘Ghost providers’ could mislead enrollees in selecting a plan,” it added.