Private Medicare and Medicaid Insurance Plans Falsely List Mental Health Professionals Available for Treatment
A recent report by the Office of Inspector General for the Department of Health and Human Services has uncovered a troubling trend among companies running private Medicare and Medicaid insurance plans. The investigators found that many mental health professionals listed as available to treat the plans’ members are inaccurately represented. Some insurers have been accused of creating “ghost networks” of psychologists, psychiatrists, and other mental health professionals who supposedly agreed to treat patients covered by the publicly financed Medicare and Medicaid plans. However, a significant number of these professionals do not have contracts with the plans, do not work at the listed locations, or are retired.
The report focuses on insurers that the government pays to cover individuals in Medicare Advantage plans and privately managed Medicaid plans. Approximately 30% of all Americans are covered by such insurance, with the government paying these insurers hundreds of billions of dollars annually. These companies receive set rates per person covered and are allowed to keep any money not spent on patient care. It is mandatory for insurers to have an adequate number of health care professionals under contract to serve patients in each region they cover.
The investigation revealed that 55% of mental health professionals listed as in-network by Medicare Advantage plans were not providing care to any of the plans’ members, while the figure was 28% for Medicaid managed care plans. Some professionals interviewed by investigators stated that they should not have been listed as in-network care providers because they no longer worked at the locations listed, did not participate in the plans, or were no longer providing patient care.
One case highlighted in the report involved a private Medicaid plan listing a mental health professional as providing care in 19 practice locations. However, upon investigation, it was discovered that the individual had retired several years ago. This misleading information can have serious consequences for patients in need of mental health care, as demonstrated by the experience of Jeanine Simpkins from Mesa, Arizona. Simpkins struggled to find a drug rehabilitation program that accepted the Medicare Advantage insurance of her family member in crisis, ultimately resulting in enrollment in part-time hospital care instead of inpatient rehabilitation.
The report emphasizes the challenges faced by patients in accessing timely and nearby care for various health issues, with mental health care being particularly crucial. Jodi Nudelman, a regional inspector general involved in the report, highlighted the vulnerability of individuals seeking mental health care and the importance of removing any obstacles that may deter them from seeking help. The report also emphasized the importance of insurers meeting their obligations to provide sufficient care options for Medicare and Medicaid participants.
To address these issues, the report recommends utilizing medical billing data to verify the provision of care by health professionals listed as in-network. It also suggests creating a national, searchable directory of mental health providers that specifies which Medicare and Medicaid insurance plans each provider accepts. Such a directory would facilitate patient access to care and enable verification of the accuracy of insurers’ listings of in-network providers.
Federal administrators overseeing Medicare and Medicaid have taken steps towards implementing these recommendations, with the support of managed care companies. The industry recognizes the need for improvement and is committed to working with policymakers to enhance access to mental health services for Medicare and Medicaid participants.
