Private Medicare and Medicaid plans overhype in-network mental health options, watchdogs say
Companies that manage private Medicare and Medicaid insurance plans incorrectly list many mental health professionals as available to treat members of those plans, according to a new federal watchdog report.
Investigators say some insurers effectively set up “ghost networks” of psychologists, psychiatrists and other mental health professionals who allegedly agreed to treat patients covered by state-funded Medicare and Medicaid plans. In fact, many of these professionals do not have contracts with the plans, do not work in the listed locations or are retired, investigators said.
The Department of Health and Human Services’ Office of Inspector General, which oversees the giant Medicare and Medicaid health programs, released its findings in a recent report.
The report focuses on insurers that the government pays to cover people in Medicare Advantage plans and privately managed Medicaid plans. About 30% of all Americans are covered by such insurance, the report said. The government pays insurers hundreds of billions of dollars each year.
Companies receive fixed rates per person they cover and are allowed to keep the money they don’t spend on patient care. Insurers are required to have a sufficient number of healthcare professionals under contract to serve patients in each region they cover.
But the new report finds that 55 percent of mental health professionals listed as in-network by Medicare Advantage plans did not provide such care to any of those plans’ members. This figure was 28% for Medicaid managed care plans.
Some mental health professionals told investigators they should not have been listed as in-network care providers for the insurers’ members because they no longer worked in the listed locations or because they did not participate in Medicare Advantage or Medicaid managed care plans. Others said they were working as administrators and no longer providing patient care.
In one case, the report said, a private Medicaid plan listed a mental health professional as providing care in 19 practice locations. But when investigators checked, a receptionist at one of the clinics said the person had retired a few years ago.
Jeanine Simpkins of Mesa, Arizona, discovered how thin networks can be when a 40-year-old family member was in crisis this fall. Simpkins had difficulty finding a drug rehabilitation program that would accept the Medicare Advantage insurance the parent has because of a disability.
Simpkins said she contacted about 20 rehab programs, none of which would cover the Medicare insurance plan. “We feel a little abandoned,” she says. “I was quite surprised, because I thought we had something good in place for her.”
Simpkins’ relative eventually enrolled in part-time inpatient care instead of an inpatient rehabilitation center.
It can be difficult for patients to find nearby, timely care for everything from colds to cancer.
But Jodi Nudelman, a regional inspector general who helped write the federal report, said in an interview that the stakes can be particularly high for patients seeking mental health care.
“They can be particularly vulnerable,” she said. It can be intimidating for people to recognize they need such care, and any obstacles can discourage them from seeking help, she said.
She added that taxpayers won’t get their money’s worth if insurers don’t meet their obligations to provide sufficient care options to participants in Medicare and Medicaid plans.
The federal report focused on a sample of 10 counties in five states: Arizona, Iowa, Ohio, Oregon and Tennessee. It included urban and rural areas. She did not identify the insurers whose networks were audited.
Susan Reilly, vice president of communications for the Better Medicare Alliance, a trade group representing Medicare Advantage plans, said managed care companies support federal efforts to improve access to mental health services. “While this report examines a small sample of projects, we agree that there is still work to be done and we are committed to continuing this progress in collaboration with policymakers,” she said in a statement.
The report’s authors said their sample was a good representation of the national situation. It examined 40 Medicare Advantage plans and 20 Medicaid managed care plans.
The report recommends that government administrators make greater use of medical billing data to confirm whether health care professionals listed as in-network provide 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 which Medicare and Medicaid insurance plans each accepts. Such a directory would help patients find care and make it easier to verify the accuracy of in-network provider lists in plans, they said.
Federal administrators overseeing Medicare and Medicaid have taken steps to create such a directory, the authors said. Reilly, the industry representative, said managed care companies support the effort.
