Major conclusions of federal report
A new federal monitoring report has stated that companies running private Medicare and Medicaid insurance schemes give a list of many mental health professionals available for the treatment of members.
Investigators have alleged that some insurance companies have set up "ghost networks" of psychologists, psychiatrists, and other mental health professionals, which are alleged to treat patients under publicly financed Medicare and Medicaid schemes.
Investigators said that in fact, many of these professionals do not have a contract with the schemes, do not work at listed locations, or have retired.
The Inspector General of the Health and Human Services Department, which oversees huge Medicare and Medicaid health programs, has recently released its conclusions in a report.
The federal report was centered on samples from 10 counties in five states: Arizona, Iowa, Ohio, Oregon, and Tennessee. It included urban and rural areas. In this, the names of those insurance companies whose networks were checked were not disclosed.
The report focuses on insurance companies that are paid by the government to cover people in Medicare Advantage schemes and privately managed Medicaid schemes. According to the report, about 30% of Americans come under such insurance. The government pays hundreds of billions of dollars annually to insurance companies.
Companies are paid at fixed rates for each person covered by them, and they are allowed to keep the amount that they do not spend on the care of patients. For insurance companies, it is necessary that they contract a sufficient number of healthcare professionals to serve the patients in each area covered by them.
But the new report found that 55% of mental healthcare providers listed in the network of Medicare Advantage schemes were not providing such care for any scheme. This figure was 28% for Medicaid Managed Care Plans.
Some mental health professionals told the investigators that they should not be listed as network care providers for members of the insurance companies because they did not work at the listed places anymore or because they did not participate in Medicare Advantage or Medicaid Managed Care Plans. Others said that they were working as administrators and no longer provided patient care.
It was said that in one case, a mental health professional was listed as providing care at 19 locations. But when the investigators checked, a clinic's receptionist told them that the person had retired a few years ago.
Patient stories and expert insights
Jeinin Simpkins of Mesa, Arizona saw how weak the network can be during the crisis of their 40-year-old family member. Simpkins had great difficulty finding a treatment program that could accept the Medicare Advantage insurance received by their relative due to disability.
Simpkins said that she contacted about 20 rehabilitation programs, and none accepted the Medicare insurance scheme.
"You feel like you've been abandoned," she said. "I was very surprised because I thought that we had some good options for him."
Simpkins’s relative had to enroll in part-time hospital care instead of a rehabilitation center.
From winter to all types of health problems, it can be challenging for patients to get nearby care.
But the Regional Inspector General Nudelman, who helped write the federal report, said in an interview that the risks for patients who need mental health care can be particularly severe.
"They can be especially vulnerable," he said. "It can be difficult for people to accept that they need such care, and any obstacle can discourage them from trying to get help."
He said that if the insurance companies fail to meet their obligations to provide adequate care options for participants in Medicare and Medicaid schemes, then taxpayers are not getting full value for their money.
Susan Reley, Vice President of Communications for the Better Medicare Alliance, which represents Medicare Advantage schemes, said that managed care companies support federal efforts to improve access to mental health services. She said in a statement, "Although this report is focused on a small sample of plans, we agree that there is still more work to do and we are committed to continuing this progress with policymakers."
The authors of the report said that their sample represents the national status. It studied 40 Medicare Advantage schemes and 20 Medicaid Managed Care schemes.
Recommendations and next steps
In the report, government administrators have been recommended to confirm whether the healthcare professionals listed in the network are actually providing care to patients under private Medicare and Medicaid insurance plans.
The monitoring team has also suggested creating a national, searchable directory of federally regulated mental health providers, listing which providers accept Medicare and Medicaid insurance schemes. They said such directories will help in finding care and make it easier to verify the accuracy of the lists used in network schemes.
The authors said that the federal administrators who supervise Medicare and Medicaid have taken steps toward creating such directories. Industry representative Reley said that managed care companies support this effort.
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This article was first published by KFF Health News and has been republished here under the Creative Commons Attribution–NoDerivatives 4.0 International License.
Main things for real-time coverage
Issue of Prevalence: Ghost networks affect the reach of about 30% of Americans under these schemes, worsening the mental health crisis, where timely care is crucial.
Decrease in Inspection: OIG has demanded better oversight and a national directory of claims — steps that have been started by CMS but not yet fully implemented.
Impact on the Patient: Stories like Simpkins’s highlight real-world obstacles, for which policy solutions are still lacking.
Industry Reaction: Business groups acknowledge the issues but insist on cooperation; no new statement after October 21.
For the entire OIG report, visit HHS OIG. If any new information comes out, then this coverage can be updated in real-time.
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