Assemblyman Holden introduces legislation on health care ‘ghost networks’

California Assemblyman Chris Holden on Friday introduced legislation that aims to end “ghost networks” and health care provider inaccuracies by reinforcing current policy with accuracy guidelines, benchmark goals and effective enforcement methods.

A “ghost network” is a health insurance directory that includes medical professionals who are unable to meet the health care needs of patients they claim to be equipped to serve. Another issue is the care providers listed in the directory are actually out of a plan’s provider network, even though they are designated as being in-network because of their inclusion in the plan directory.

“Ghost networks should not be something we accept as reality,” Holden said in a statement. “The issue here is not the quality or the cost of care, but the actual access. This bill provides solutions for Californians struggling to find their unique care needs by making the information given to them accurate and accessible.”

California has one of the nation’s strongest laws on health plan provider directories, with existing law requiring health insurance providers to pay for out-of-network care if a consumer relied on a directory to receive those health care services. 

Holden, a Democrat who represents Pasadena and communities in northern Los Angeles County, cited recent studies that indicate some health plans have inaccuracy rates as high as 80%, and major plans such as Anthem and Kaiser have inaccurate information for 20% to 38% of providers. As a result, the resulting inaccurate rosters of health care providers are referred to as “ghost networks” because they do not actually exist.

“If a health plan’s provider directory is not up-to-date, someone may end up paying more for their care, or not be able to access proper care at all,” Jose Torres Casillas, policy advocate for the consumer advocacy group Health Access California, said in a statement. “Improving compliance laws are a key way that the state can ensure that these directories are accurate. We thank Assemblymember Holden for introducing AB 236 to ensure that these directories are audited regularly so California health consumers can have faith that they are getting the best information possible to make decisions for their care.”

While California has regulations for provider directories, consumer protections are not effectively enforced, according to Holden. The Department of Managed Health Care has taken just five enforcement actions, each resulting in small fines for violators. For a lot of health insurance companies, there is not much incentive to adhere to existing rules on care provider directories because of the infrequency and fiancial insignificance of fines levied. 

If enacted, Holden’s AB 236 would work with health care providers to incentivize compliance and would ensure that the information provided to plan enrollees is accurate.

The proposed law seeks to establish specific benchmarks for health plans provider directories: 60% accuracy by Jan. 1, 2024 and 80% accuracy by Jan. 1, 2025, according to Holden. AB 236 would also require annual audits and verification by health plans of provider directories for accuracy of all required information.

“Health is an important facet to help our communities thrive,” Holden said in a statement. “Affordable, accessible and quality care for all Californians is what we want.”