Screening for Rate of Ghost Physicians in Provider Directories

Area of Science:

• Health Services Research
• Health Policy
• Health Informatics

Background:

• Provider directories are crucial for patient access to care in health plans.
• Inaccurate provider directories, including 'ghost networks,' can lead to patient confusion and barriers to care.
• Medicare Advantage (MA) plans rely on accurate provider listings for beneficiary access.

Purpose of the Study:

• To establish a conceptual framework for understanding ghost networks.
• To introduce a novel methodology for quantifying ghost physician prevalence within health plan provider directories.
• To assess the prevalence of ghost primary care physicians (PCPs) in MA plans.

Main Methods:

• Categorized PCPs into general ghosts (unavailable to any Medicare beneficiaries) and network-specific ghosts (unavailable to specific MA network enrollees).
• Utilized multiple data sources, including Ideon MA provider directory data, NPI registry, and OneKey database.
• Employed a logistic model to differentiate truly unavailable physicians from those with low patient volume due to chance.

Main Results:

• 17.5% of listed PCPs in an average MA network were general ghosts.
• 11.5% of listed PCPs were network-specific ghosts.
• Health maintenance organization networks and networks with low star ratings exhibited higher ghost PCP prevalence.

Conclusions:

• Provider directories must accurately reflect physician availability for patient care.
• The proposed methodology can support targeted network audits to improve directory accuracy.
• Ensuring directory accuracy is essential for effective healthcare delivery and policy.