Medicaid managed care plans have a provider directory problem, with the latest data from the HHS Office of Inspector General finding that many of these plans have inaccurate provider directories that impact patient access to care.
The report, which focused specifically on maternal healthcare providers, found a mix of problems. While some managed care plans listed providers in their directories who were not actually in-network, others were missing in-network providers. For some plans, the issue was having accurate contact information listed for in-network providers.
This is problematic, OIG said, especially in the maternal health space where the U.S. is contending with poor outcomes and comparatively high mortality rates. Medicaid, in particular, pays for more than 40% of births in the U.S., and most pregnant Medicaid enrollees are covered by a managed care plan.
When beneficiaries cannot find an in-network provider, they become less likely to access the prenatal and maternity care necessary to promote good birthing outcomes.
Where provider directories fall short
OIG assessed the provider directories for Centene, Elevance and UnitedHealthcare managed care plans in five states. These plans represent the three largest parent companies operating Medicaid managed care plans in the U.S., collectively covering 29 million enrollees in 38 of the 42 states with these types of plans.
Provider directories fell short in offering accurate plan information, OIG found. Overall, 9% of the providers in the three plans' directories were out-of-network, otherwise known as "ghost providers."
More specifically, 22% of the providers in Centene's directories were not actually in-network. That problem was less common for Elevance (4%) and UnitedHealthcare (6%).
On the flip side, the three payers had a sizeable proportion of in-network providers missing from their directories. For Centene, that figure was 35%, while Elevance had 11% of in-network providers missing and UnitedHealthcare was missing 25% of in-network providers.
Lacking accurate information about which providers are in-network is problematic, as it limits members' ability to make informed decisions about where they'll access care. When a patient believes a provider is in-network and they aren't, the patient must restart their search for a maternal health provider. According to OIG, this could delay care, which could adversely impact outcomes.
Ghost providers might also negatively influence plan selection, OIG pointed out. Many consumers look at provider directories before selecting a plan to ensure their usual source of care is in-network. Ghost providers might lead some enrollees to choose the wrong plan due to inaccurate information.
On the flip side, missing in-network providers from the provider directory artificially limits patients' options for clinical care. This is problematic as the nation already faces a provider shortage, and access to care is challenging.
But Centene, Elevance and UnitedHealthcare have more than just a network-status problem in their provider directories. Even when directories correctly list a provider as in-network, there's a decent chance their contact information is incorrect.
For example, 37% of Centene's in-network providers had inaccurate contact information listed. For Elevance, that number was 41%, while for UnitedHealthcare, it was 22%.
In other words, members have anywhere from a one-in-five to a two-in-five chance of dialing the wrong number when trying to book a maternity care appointment, or of learning that the office is not as conveniently located as they thought. This could lead to an adverse member experience and, at worst, foregone care.
Fixing inaccurate provider directories requires oversight
Solving this problem is an essential part of addressing the nation's maternal health issues, OIG indicated. Because Medicaid managed care plans, and especially these three plans, cover so many people, it will be integral that state and federal bodies pull the necessary levers to ensure accurate provider directories.
Notably, OIG pointed to a federal policy beginning July 10, 2028, that requires states to conduct secret-shopper surveys to verify the accuracy of Medicaid managed care plan online provider directories. But without an enforceable standard, these surveys might have limited impact.
Instead, OIG stated that CMS should promote the use of encounter data to flag inactive providers in provider directories and to identify in-network providers missing from directories.
OIG also urged CMS to continue assessments to determine whether a National Directory of Healthcare Providers and Services could help improve directory accuracy and lessen patient burden.
Finally, OIG suggested CMS work with states to hold Medicaid managed care plans accountable for inaccurate provider directories. Accountability measures might include implementing state performance standards for directory accuracy, stronger contract language requiring accurate provider directories and stronger penalties for poor directory accuracy.
CMS agreed with OIG's suggestions.
Sara Heath is an executive editor at Xtelligent Healthcare Media, where she covers patient engagement, healthcare policy and health IT.
