Private Medicare and Medicaid plans overstate in-network mental health options, watchdogs say

A new federal watchdog report says companies that operate private Medicare and Medicaid insurance plans inaccurately list many mental health professionals as available to treat plan members.

Investigators allege that some insurance companies effectively created “ghost networks” of psychologists, psychiatrists and other mental health professionals who allegedly agreed to treat patients covered by publicly funded Medicare and Medicaid plans. In fact, investigators said many of these professionals do not have contracts with the plans, do not work at the locations listed, or are retired.

The Department of Health and Human Services’ Office of Inspector General, which oversees the giant health care programs Medicare and Medicaid, released its findings In a recent report.

The report focuses on insurers that the government pays to cover people in Medicare Advantage plans and in privately run Medicaid plans. The report says that about 30% of all Americans are covered by this insurance. The government pays insurance companies hundreds of billions of dollars annually.

Companies get set rates for each person they cover, and are allowed to keep any money they don’t spend on patient care. Insurers must have sufficient numbers of health care professionals under contract to serve patients in each area they cover.

But the new report found that 55% of mental health professionals in-network through Medicare Advantage plans did not provide such care to any plan members. This number was 28% for Medicaid managed care plans.

Some mental health professionals told investigators that they should not be listed as in-network providers for insurance company members, because they no longer work in the listed locations or because they do not participate in Medicare Advantage or Medicaid managed care plans. Others said they were working as administrators and were no longer providing care to patients.

In one case, the report says, a private Medicaid plan listed a mental health professional providing care at 19 practice sites. But when investigators checked, a receptionist at one clinic said the person had retired a few years ago.

Jeanine Simpkins of Mesa, Arizona, learned how vulnerable networks can be when a 40-year-old family member had a crisis this fall. Simpkins struggled to find a drug rehab program that accepted the relative’s Medicare Advantage insurance because of a disability.

Simpkins said she contacted about 20 rehab programs, and none of them accepted the Medicare insurance plan. “You feel like you kind of fell,” she said. “I was very surprised, because I thought we had something good for her.”

Simpkins’ relative eventually entered part-time hospital care instead of an inpatient rehabilitation center.

It can be difficult for patients to find close, timely care for all kinds of health problems, from the common cold to cancer.

But Judy Nudelman, the regional inspector general who helped write the federal report, said in an interview that the risks can be particularly high for patients seeking mental health care.

“They can be particularly vulnerable,” she said. She said it can be difficult for people to admit they need such care, and any bump in the road could discourage them from trying to get help.

She added that taxpayers are not getting their money’s worth if insurance companies fail to meet their obligations to provide adequate care options for Medicare and Medicaid participants in the plans.

The federal report focused on a sample of 10 counties in five states: Arizona, Iowa, Ohio, Oregon, and Tennessee. Included urban and rural areas. The insurance companies whose networks were examined were not specified.

Managed care companies support federal efforts to improve access to mental health services, said Susan Riley, vice president of communications for the Better Medicare Alliance, a trade group that represents Medicare Advantage plans. “While this report looks at a small sample of plans, we agree that there is more work to do and we are committed to continuing this progress with policymakers,” she said in a statement.

The report’s authors said their sample was a good representation of the national situation. I looked at 40 Medicare Advantage plans and 20 Medicaid managed care plans.

The report recommends that government officials make greater use of medical billing data to ascertain whether in-network health professionals are providing care to patients covered by private Medicare and Medicaid insurance plans.

The watchdogs also recommend that federal regulators create a searchable national directory of mental health providers, listing the Medicare and Medicaid insurance plans each accepts. Such evidence would help patients find care and would make it easier to double-check the accuracy of plan listings for in-network providers, they said.

Federal officials overseeing Medicare and Medicaid have taken steps toward creating such a guide, the authors said. Managed care companies support the effort, said Riley, the industry representative.