Study finds rampant 'phantom' docs on Medicaid network directories in Oregon

A new study found most network directory listings in Oregon’s Medicaid program were “phantom” providers that didn’t take Medicaid payments.

The findings, outlined in a study in Health Affairs published Tuesday, comes as the Senate is exploring how to tackle pay parity between mental and behavioral health as well as network adequacy for mental health providers.

“Based on our analysis of claims data, only a third of mental health prescribers listed in directories provided care to Medicaid patients in 2018,” the study said. “Although federal parity laws prohibit health plan designs that dissuade people with high-cost chronic mental health conditions from enrolling, the composition of provider networks is one design element that remains difficult to regulate.”

Researchers looked at members in Oregon’s Medicaid program under 64 in 2018, excluding all dual-eligible beneficiaries. They also looked at provider directories for 15 coordinated care organizations that include both Medicaid managed care and accountable care organizations.

They then calculated the provider-to-enrollee ratios to explore how many providers are in each service area. They found that nearly 60% of network directory listings were “phantom” providers thst did not see Medicaid patients. This includes 67% of mental health prescribers and 59% of mental health non-prescribers as well as 54% of primary care doctors. 

“Significant discrepancies between the providers listed in the directories and those whom enrollees can access suggest that provider network monitoring and enforcement may fall short if based on directory information,” the study said. 

The findings underscore the problem defining network adequacy in Medicaid, especially for mental health.

“Although limited to one state, our findings suggest significant discrepancies between provider directories and the actual availability of providers,” researchers wrote.

Relying solely on the network directories may also not be enough for federal and state regulators to monitor adequacy standards. 

The findings also come as Congress is taking a longer look at gaps in mental health access, especially amid the COVID-19 pandemic. The Senate Finance Committee is working on a package of legislation to address mental health access, including bolstering the workforce and ensuring parity between payments for behavioral and mental health. 

A report from the committee released earlier this year also touched on the problem of finding in-network mental health providers.

“Without adequate in-network access, patients are more likely [to] go out of network for behavioral health services,” the report said.