May 03, 2023

ICYMI: At Hearing, Warren Slams Medicare Advantage Plans for Error-Laden Provider Directories and Distorted Networks, Calls for Stronger Oversight

“If these Medicare Advantage plans continue to mislead beneficiaries about covered providers, at the same time that they are overcharging taxpayers for this crummy coverage, then we should be taking another look at whether or not MA plans should continue to enjoy the privilege of restricting provider networks at all.”

Video of Exchange (YouTube)

Washington, D.C. – At a hearing of the Senate Finance Committee, U.S. Senator Elizabeth Warren (D-Mass.), highlighted the prevalence of ghost networks in Medicare Advantage plans and called for stronger oversight of the program. In response to questions from Senator Warren, Mary Giliberti, Chief Public Policy Officer at Mental Health America, pointed out the alarming number of inaccuracies in Medicare Advantage plan provider directories, the effects of these errors on network adequacy, and the impact for patients.

Transcript: Barriers to Mental Health Care: Improving Provider Directory Accuracy to Reduce the Prevalence of Ghost Networks
U.S. Senate Committee on Finance 
Wednesday, May 3, 2023

Senator Elizabeth Warren: Thank you. So America is facing a mental health crisis. One in five Americans live with a mental illness and for Medicare beneficiaries, it's one in four. 

Federal law requires Medicare to cover mental health services in both traditional Medicare and Medicare Advantage, or MA. The program that allows private insurance companies to offer Medicare coverage. 

Now, unlike traditional Medicare, the private insurance companies in Medicare Advantage can establish networks to restrict the doctors or facilities that beneficiaries can use. So if your doctor is in network, the plan will cover those services for a small co-pay, but an out of network doctor can leave patients with skyrocketing costs. This can be especially devastating for seniors or for people with disabilities, who are more likely to be living on fixed incomes. 

To help beneficiaries avoid these surprise costs, MA plans are required to publish directories, which enrollees can use to find new doctors or to make sure their existing doctors are covered. So let's start with what we know about the accuracy of these directories. There have been some references to them. But Miss Giliberti did I say right Miss Giliberti? What do we know about the accuracy of the provider directories in Medicare Advantage? 

Mary Giliberti, Chief Public Policy Officer, Mental Health America: So CMS has done some audits, Senator and what they found was, on average, the accuracy rate was about 45%. 

Senator Warren: What does that mean that the accuracy rate is 45%? 

Ms. Giliberti: You know, they found in 2018, I think it was, you know, almost 50% had at least one inaccuracy. So, you know, we're seeing a good deal of inaccuracies that's with physical health care, just say there's a gap in data because they haven't done this for behavioral health. 

Senator Warren: And might we surmise that behavioral health accuracy–

Ms. Giliberti: It's always worse.

Senator Warren: It's always worse. It's always worse. Okay. So you think you've got a list of people you can go to, and the odds are actually in favor of the list is wrong? And probably even worse on behavioral health. 

All right, so here, we've got a patient who does everything right, they still may be hit with a huge bill, because the directory has outdated or inaccurate information. Or they might call up every doctor only to find out that we've heard about some of this phone numbers don't work. They're not accepting new patients. I think we've heard the story about this and appreciate you being here to talk about your story. Ms. Myrick, we know that MA plans use all kinds of tricks and traps to squeeze more money out of Medicare, they got a lot of different ways that they do this to boost their numbers. But here's the one I want to focus on. Do these MA plans stand to gain anything from having inaccurate information? In other words, is it inaccurate because you just haven't spent enough money to make it accurate? Or is it inaccurate by design?

Ms. Giliberti: Well, I think there are advantages that they have when their directories, unfortunately, are inaccurate. If they use those directories for network adequacy standards, for example, they might meet the standards, but they're not accurate. People make choices based on what they see as their network. So if it looks like a bigger network, but it's not real, people are choosing a plan. 

Senator Warren: So it's a way to defraud consumers to say I have this really big list of people you could go to if you had a problem. And it turns out that really big list if it were accurate is actually this little tiny list. Right? 

Ms. Giliberti: Right.

Senator Warren: Okay. And that's one way it's to their to the advantage of Medicare Advantage plan, in order to be inaccurate, they get paid in effect, or they make more money by being inaccurate. Did you have another one? 

Ms. Giliberti: Well, just that, oh, think it's about 60% of the plans don't have out of network coverage. So if you get really frustrated and you pay on your own, then they're not paying anything. So the more I can frustrate you,he more that I meaning the Medicare Advantage plan, the more the Medicare Advantage plan can frustrate you, the more you'll just go somewhere else. And that means it's not money out of their pockets. Can we get the two main ones you wanted to add. 

Jack Resneck Jr., President, American Medical Association: I just was going to add, Senator, this is yes, this. We see this all the time. This is health plans, delaying and denying care, that same patient once they finally find the needle in the haystack and even get to a physician who's in network and sit down and get a diagnosis and a treatment plan then goes to the pharmacy and discovers the health plan has requires (inaudible) for the treatment for that condition which then it takes weeks to get approved. Sometimes they never go back to the pharmacy, they give up their mental health or their or their other chronic condition gets worse. 

Senator Warren: So conditions get worse and they don't have to pay for the treatment, this Medicare Advantage plan. So look, what we're really saying here is that it is in the financial interests of these Medicare Advantage plans to discourage beneficiaries from accessing care. We also know that the Medicare Advantage plans are paid a set amount per beneficiary, which can be dialed up if the beneficiary is sicker. So the more diagnosis codes that the beneficiary has, the higher the payment, the insurance companies have built entire businesses around making these beneficiaries look as sick as possible, and then overcharging taxpayers by hundreds of billions of dollars. Because here's the key that underlines this. Whatever insurers don't spend on care, as a result of tactics like outdated provider directories or overly restrictive networks or inaccurate information, whatever they don't spend on care they get to keep. So let me ask you one last question on this. What penalties, Ms. Giliberti, do MA plans face for being out of compliance with regulations and provider directories and network adequacy? So we got a bunch of rules when they're in violation of the rules? What's the consequence?

Ms. Giliberti: I'm not aware of any penalties, Senator. The audit that I mentioned earlier talks about like notices of noncompliance and warning letters, but they don't mention anything about penalties. So, I know there's been some legislative proposals to that effect, but I'm just not aware of any penalties that are being assessed.

Senator Warren: I tell you nobody's jumping in with any other answer. You know, this is the part that just drives me crazy, people look at the regulation, they think, oh, well, we're going to be okay. Because this is regulated. But we're not okay, if there's no enforcement. Now, to the extent they have enforcement tools, CMS really needs to step up the enforcement here at a minimum. Beneficiaries should not be on the hook for out of network costs that were incurred because of inaccurate directories, that'd be a nice starting place on this. CMS should also penalize Medicare Advantage plans that are out of compliance, just put penalties on these guys. And it's Congress's job to put tougher regulations in place. 

And I also want to say this, if these Medicare Advantage plans continue to mislead beneficiaries, about covered providers, at the same time that they are overcharging taxpayers for this crummy coverage, then we should be taking another look at whether or not MA plans should continue to enjoy the privilege of restricting provider networks at all. 

Now, there's a serious question that should be on the table. If they can't do better in managing these restricted networks, then maybe they ought to have to cover anyone who's a licensed practitioner that you'd go to see.