Your plan's doctor list can be wrong

Insurance companies publish a list of doctors in your plan. That list is often wrong. A Senate committee called 120 listed mental health providers in 2023 and could book an appointment 18% of the time. Check your own doctor before you enrol, and keep a record of what the list said.

By Brett Spain · Published · Last updated

What a provider directory is

Every health plan has a network. The network is the set of doctors, clinics and hospitals the insurer has a contract with. See a doctor inside the network and you pay the plan's normal share. See one outside it and you can pay much more, or all of it.

The provider directory is the list of who is inside. It sits on the insurer's website. You search it by name, by town, by speciality. Most people use it once, at the moment they are choosing a plan, and then trust it for a year.

That is the problem. The list is a snapshot of a thing that moves.

How often the list is wrong

In 2023 the U.S. Senate Finance Committee ran a small, careful test. Staff took directories from 12 Medicare Advantage plans across 6 states and phoned 10 mental health providers from each. That is 120 calls.

Of those 120 listings, 33% were wrong, unreachable, or never called back. Staff managed to book an appointment 18% of the time. The rate ranged from 0% in Oregon to 50% in Colorado. The committee's conclusion was that more than 80% of the listed, in-network mental health providers it tried to reach were "ghosts" — unreachable, not taking new patients, or not actually in the network.

That was 120 calls in one speciality. It is a small sample, and the committee says so. But it is a real one, made by hand, and nobody has produced a better result since.

We also check this at scale in our own database, against the federal provider registry rather than by telephone, and we publish those figures with the date each one was computed in Ghost networks by the numbers.

What the law already requires

This is not a gap in the rules. The rules exist.

Federal law at 42 U.S.C. §300gg-115 tells your plan to:

Doctors have a matching duty under 42 U.S.C. §300gg-139 to send their plans up-to-date information when they join a network, when they leave one, and whenever their details materially change.

For plans sold on the federal exchange, CMS also requires the machine-readable provider file to be updated "no less frequently than a monthly basis", and says it crawls those files daily.

So the standard is a directory that is never more than 90 days stale. The evidence says the real thing falls well short of that.

Why the list goes stale

None of this needs anyone to be acting in bad faith.

A doctor retires. A practice moves two towns over. A group leaves one insurer's network and joins another's. A physician dies. A clinic gets bought and its billing entity changes. Each of these is a small paperwork event at the practice, and a row that nobody edits in a database at the insurer.

There is also a structural reason. The insurer builds the directory from what practices send it, and practices send it to dozens of insurers in dozens of formats. Nobody owns the whole picture. A wide network is a selling point, so there is no commercial pressure to prune it either.

The result is a list that grows more easily than it shrinks.

How to check a doctor before you pick a plan

Do this before you enrol, not after.

  1. Search the insurer's directory for your doctor by name, and note the exact plan name — not just "Blue Cross", but the specific plan you are buying.
  2. Phone the doctor's office and ask: "Are you in network for this exact plan in this plan year, and are you taking new patients?" Practices know their own contracts better than the directory does.
  3. Phone the insurer and ask the same question. Under the law above, they have to answer you in writing within one business day.
  4. Save what you are told. Screenshot the directory page with the date visible. Keep the written answer from the insurer. Write down who you spoke to and when.

Step 4 is the one people skip, and it is the one that matters later.

If the provider you are checking treats addiction or mental health, expect the hardest case. The Senate test above looked at exactly that population. It helps to start from a list built from the facilities' own federal survey returns rather than from an insurer's contract file. We publish one: find licensed addiction and mental health treatment on aSoberBed.

aSoberBed is operated by Spain Companies LLC, the same company that operates AllowanceHealth. Treat that link as our own sister site, not an independent recommendation. No money changes hands when you follow it. About the Spain care network.

What to do if you get a surprise bill

If you relied on the plan's own directory or its own phone answer, and it told you a provider was in network, and the provider turns out not to be, federal law limits what you can be charged.

Under 42 U.S.C. §300gg-115(b), for plan years starting on or after 1 January 2022, the plan may not charge you a cost-sharing amount higher than the in-network amount for that item or service, and it has to count it against your in-network deductible and out-of-pocket maximum. This applies where you got the wrong information from the directory, the database, or the plan's phone response protocol.

That protection is why the record you kept in step 4 is worth keeping. The rule is about what you were told, so the evidence of what you were told is the whole case.

This is a general description of a federal rule, not legal advice, and there are more conditions in the statute than fit here. If it is a large bill, read the section itself or get help from someone who does this for a living.

What we do about it

We are not the ones who can fix an insurer's database. What we can do is keep a dated record of what it said.

Every day we capture insurer provider directories and the federal machine-readable files, hash them, and store the fact that the file existed in exactly that form on exactly that date. When a plan quietly edits a listing, the edit is visible, because the earlier version is still there. That archive is what the continuity record shows, and it is what the counts in Ghost networks by the numbers are built from.

We are paid by employers for advisory work. We are not paid by any insurance company and we earn nothing when you enrol in a plan, so we have no reason to tell you a network is better than it is.

Questions people ask

How often does my insurer have to update its doctor list?

At least once every 90 days for the online directory, under 42 U.S.C. §300gg-115. It also has to apply an update within 2 business days of a provider telling it something changed. Plans on the federal exchange must refresh their machine-readable provider file at least monthly.

The directory says my doctor is in network. Is that enough?

No. Treat it as one of two sources. Phone the practice and ask about your exact plan, and phone the insurer and get the answer in writing. Keep both.

I was billed out-of-network for a doctor the directory listed as in-network. What now?

Federal law says the plan cannot charge you more than the in-network cost-sharing in that situation, and must apply the in-network deductible and out-of-pocket maximum. Contact the plan, quote 42 U.S.C. §300gg-115(b), and send the record of what the directory or the phone line told you.

Does this only affect mental health providers?

No. The Senate study looked at mental health providers because access problems there are severe, but the directory data itself is maintained the same way for every speciality. Our own checks cover all provider types.

Are these directories wrong on purpose?

We have no evidence of that and we do not claim it. What the data shows is a maintenance failure, not intent. A stale row in a database is a data-quality problem, and it is still your problem when the bill arrives.

Where do your numbers come from?

Our figures come from queries against our own copy of the federal provider registry cross-checked against insurer directory rows, and each one carries the date it was computed. The counts, the full method and what they do not prove are all in Ghost networks by the numbers. The Senate figures above come from the committee's own published staff report.