Busting ‘ghost’ medical networks is a big job
Perhaps you’ve had this experience. You consult your insurer’s provider directory to find an in-network primary care physician or specialist. You start making phone calls, only to learn that the providers a) aren’t taking new patients; b) aren’t in your network; c) aren’t at that phone number; d) don’t have availability for six months; or e) all of the above.
And so you have a “ghost” of a chance of getting an appointment because the provider directory is littered with out-of-date, misleading or wrong information. The problem is known in the industry as “ghost medical networks,” and it’s getting attention from state and federal regulators.
It is spooky season after all.
The problem is especially acute with Medicaid and Medicare providers as well as behavioral health providers. It’s sad that an individual having a mental health crisis has to make two dozen phone calls to find a psychiatrist. Some may just give up.
Here’s the uncomfortable truth: While the Affordable Care Act expanded access to poor patients through Medicaid, the reimbursement rates are so low that many doctors cannot afford to take on more patients than they already have. The same is true for Medicare and Medicare Advantage providers.
Meanwhile, insurers are required to meet “network adequacy” standards ― having enough providers to serve the population in a particular area. Often, however, adequacy does not translate into access, especially in rural and poor communities. Increasingly, “ghost networks” are seen as a barrier to medical care.
A 2025 report from the Health and Human Services Inspector General found that many private insurers maintain directories packed with “ghost” providers who are inactive, no longer accepting patients or impossible to reach. Federal rules require directories to be updated quarterly or within 30 days of changes, but the report showed that compliance is uneven.
Insurance companies often say these problems are unintentional and that they work hard to keep their directories up-to-date.
It’s true that provider information is constantly changing, and the system isn’t designed to keep up with it. A Colorado doctor is proposing that artificial intelligence may be better equipped to manage provider information. Maybe this will be an instance of AI helping.
State legislatures are taking notice. In 2024, Gov. JB Pritzker signed into law the Health Care Protection Act, which requires insurers to maintain accurate, up-to-date lists of providers in their networks.
Regulating the problem on a state level doesn’t seem like a solution to me when insurance companies operate across the country and so many patients are served by federal programs. In February, President Trump signed the REAL Health Providers Act as part of the Consolidated Appropriations Act.
Starting with the 2028 plan year, Medicare Advantage plans ― which cover the majority of Medicare-eligible Americans ― will be required by law to verify and update their provider directories every 90 days. Patients who “reasonably” rely on outdated directory information are protected from paying out-of-network prices.
Directories would be audited by Centers for Medicare & Medicaid Services for accuracy using a variety of methods, including perhaps AI. Hopefully, enforcement actions like fines will encourage the insurance companies to shape up.
As I often point out, the U.S. healthcare system is so fragmented and hard to navigate that many patients are left with inadequate care or no care at all. A good patient advocate is familiar with the resources in their particular area and can help you find a doctor when a “ghost network” lets you down.
• Teri (Dreher) Frykenberg is a registered nurse and board-certified patient advocate. She is the author of several books on advocacy and founder of Nurse Advocate Entrepreneur, which equips medical professionals with the knowledge and skills to start their own advocacy businesses. Contact her at Teri@NurseAdvocateEntrepreneur.com.