Ghost Networks

In UnitedHealthcare’s online directory of in-network physical therapists, there are sixty-three clinics listed within Boulder County, which includes the cities of Boulder, Longmont, Louisville, and Lafayette. The Lever analyzed the list and found that sixteen clinics either do not provide physical therapy, are out-of-network, or don’t seem to exist — amounting to just over 25 percent of the clinics listed.

One address in Longmont is for a strip mall with a chiropractor, optometrist, family medical practice, and sandwich shop — but no physical therapist. Another is located in a senior living community. One listing leads you to a residential mobile home park in Boulder. Additionally, many of the actual in-network physical therapy clinics are listed under the wrong name or do not have an updated address. Some of these clinics are listed multiple times under slightly different names.

In Sarah’s town, there are three physical therapy clinics listed, but only one — Sarah’s clinic — is in-network with UnitedHealthcare. One of the locations is a physical therapist who does not take insurance. The other is a dentist in a shopping plaza. Previously, the building was a primary care clinic, which closed in 2017. In the decades that Sarah has worked in the area, she has never seen a physical therapist operate in the plaza.

Along with potentially impacting her reimbursement rate from UnitedHealthcare, Sarah worries these inaccuracies impact the stream of new patients into her clinic.

Kurt LeVan, a contract manager at Optum, a health care services provider that’s a subsidiary of UnitedHealthcare, wrote to Sarah in an email this September, explaining that there were many other providers in the area. “I understand the market, the healthcare environment very well, I’m very versed in my territories I manage.”

Chris Edmundson, a physical therapist in Colorado who has been practicing for twenty years, frequently hears from clinics that are struggling with poor reimbursement rates. In Edmundson’s experience, insurers frequently point to their allegedly abundant network directories as the reason they will not increase their rates — or will not give a provider a health insurance contract.

“There were several [insurers] who said they were not even going to extend a contract to me because they have plenty of providers,” said Edmundson. “Consequently, you agree to a subpar contract and realize later, ‘Oh wow, we can’t survive like this.’ But you’re in a situation where you don’t want to stop serving your community.”

Physical therapists are far from the only health care field that appears to be plagued by erroneous provider directories.

The United States Government Accountability Office, a nonpartisan agency that investigates federal spending and performance, found that people with mental health care coverage are experiencing challenges finding in-network providers in large part because of inaccurate or out-of-date provider directories. The authors note the issue of “ghost networks” — providers who are listed as in-network but are either not taking new patients or not actually in the enrollee’s network.

A review of Medicare Advantage online provider directories by the Centers for Medicare and Medicaid Services (CMS) resulted in similarly concerning findings: almost half of provider locations listed had at least one inaccuracy, a problem that was the subject of a senate investigation this year.

In a 2023 analysis, researchers surveyed nearly 450,000 physicians in the Medicare provider database that appeared in online physician directories for UnitedHealth, Elevance, Cigna, Aetna, and Humana. They found that only 19 percent had consistent addresses and specialty information across all the directories in which they were found.

There is growing outcry over how inaccurate provider directories impact patients. A national survey found that 53 percent of patients on private insurance who used a provider directory to find a mental health provider, for example, encountered inaccuracies. Those who came across these directory inaccuracies were more likely to be treated by an out-of-network provider than other patients and were four times more likely to receive a surprise out-of-network bill.

“Inaccurate directories shift the responsibility onto patients to locate a plan’s network or pay for out-of-network care,” Jack Resneck, former president of the American Medical Association, a lobbying group for physicians and medical students, told the US Senate Finance Committee this May. “Patients are financially impacted and may be prevented from receiving timely care. Moreover, in the long run, continuing to allow inaccuracies makes it easier for plans to fail to build networks that are adequate and responsive to enrollees’ needs.”

Regarding providers, a survey found that physician practices nationwide spend $2.76 billion each year on directory maintenance.

“They’re Using a List That Is Inaccurate”

There is no national standard for what constitutes a sufficient provider network. What’s more, enforcement of such standards varies across states and insurance types.

Starting in the 2023 health plan year for marketplace plans, CMS insurer guidelines say that at least 90 percent of enrollees must live within a certain distance of at least one provider that offers primary care or specialties like cardiology and emergency medicine. CMS also proposed setting maximum appointment wait times for primary care, behavioral health, and nonurgent specialty care.

Additionally, the federal No Surprises Act, which went into effect January 2022, is meant to protect people on individual and employer-sponsored health plans from unexpected medical bills.

Many of these surprise bills result from patients receiving out-of-network emergency services, including air ambulances, or care from out-of-network providers at in-network facilities.

People can also receive a surprise invoice after seeing an out-of-network provider who is inaccurately listed as in-network on their health plan’s provider directory. Consequently, the act requires health plans to verify and update provider directory information at least every ninety days, update provider information within two business days of receiving information from a health care professional, and respond to requests about the network status of a provider within one business day.

Regardless of these steps, provider directories are still riddled with inaccuracies, and providers like Sarah are suffering the consequences.

“They’re using a list that is inadequate to justify their reimbursement rate. To not get a raise in twenty-five years is ludicrous.” said Sarah. “They’re denying me the ability to be profitable.”