Reporter Max Blau explains insurance ghost networks

Many of us have been there. You get a long list of providers from your health plan only to find that many lead to a dead end. Some don't take new patients or aren't actually part of the insurer's network. Others lack the required specialty.

ProPublica reporter Max Blau recently wrote about how that bait-and-switch - known as a ghost network - ended in tragedy for a 36-year-old man in crisis. His story, "I Don't Want to Die": Needing Mental Health Care, He Got Trapped in His Insurer's Ghost Network, detailed Ravi Coutinho's unsuccessful search to find addiction treatment in Arizona.

Blau followed up with advice for consumers who are struggling to find a mental health care provider and a column about his reporting process and reader response.

Ghost networks may contribute to deficient access to mental health care, which has prompted federal and state policymakers to consider stronger regulations. However, the term ghost network is relatively new. In an interview, Blau explained key things for journalists to know.

The following interview has been edited for brevity and clarity.

Where did the term "ghost network" come from?

Over the past decade it's shown up in academic journal articles as a catchier way of describing provider directory errors. Network accuracy describes whether the provider information being given to you as a consumer is factually accurate. There's a separate term, network adequacy, which is whether there are enough providers in a geographic area to serve all of the people who are enrolled in a health plan.

What distinguishes a ghost network from ordinary inaccuracies?

When there is a phone number that's wrong, an address that's wrong, or if you need someone for an opioid use disorder and you can't tell from the directory if that person is an addiction psychologist, regulators would consider those ghosts or phantom providers. Basically any piece of information that is off or misleading that would prevent a consumer from being able to schedule an appointment would qualify.

It sounds like ghost networks mask network inadequacy.

Absolutely. In many states there is a dynamic where insurance companies submit their provider directories as part of the compliance process. In some states they sign a document certifying that they are in compliance with the law, but then the regulator doesn't actually check. Neither the customers nor the regulators have any idea of how many providers are truly available.

Do ghost networks apply only to mental health, or is that just one particularly problematic area?

That's one particularly problematic area. They actually apply to all areas - the medical and surgical side of insurance as well as mental health.

Do we know how widespread this problem is?

No. Even most states don't have a clear sense. A lot of what we know comes from a growing body of secret shopper surveys, often with specific kinds of insurance. For instance last year the Senate Finance Committee did a ghost network survey around Medicare Advantage plans. There have been ones that focus on geographic areas, like commercial plans in a select number of cities.

How do ghost networks affect patient care?

Experts have studied this and found that policyholders are more likely to face greater out-of-pocket costs and treatment delays if they get treatment at all. The story that I wrote about Ravi Coutinho is a case study of some of the worst things that can happen when you are not able to get the kind of care that you need. The potential for harm is generally recognized by regulators, lawmakers and advocates, as well as patients who experience it firsthand.

Some states have laws regulating the accuracy of provider directories. Why have those laws been so difficult to enforce?

State agencies' enforcement arms tend to be understaffed. In some states, it's not clear how you actually hold the company accountable for adhering to the specifics of the law. And then I think there's concern from some insurance commissioners that if they are too punitive or aggressive in enforcing the law, a particular insurer might leave the marketplace and there would be fewer options for consumers. You have an agency that is tasked with bringing insurance companies to the marketplace while also having to regulate those companies and ensure compliance.

Do you have any advice for journalists who want to cover ghost networks?

Getting to understand how governments regulate insurance is a key first step. If you're focused on a particular state, ask: How is that state handling insurance issues? State insurance agencies put out reports about the work that they've done, so getting your hands on documents from those agencies could be helpful. Wherever you are there is likely a consumer advocacy organization that specializes in those issues, and I've found those individuals to be incredibly helpful in explaining how insurance affects mental health care.