Ghost networks: when the directory lies

What a ghost network is

A ghost network is an insurance directory that promises access it can't deliver. The listing is there. The clinician isn't, or isn't reachable, or retired, or never took that plan, or hasn't had an opening in two years. The patient does everything right, works the list, and still ends up nowhere.

It matters because network adequacy is a regulatory standard. Plans have to show they have enough clinicians within reach of their members. A directory full of ghosts satisfies the paperwork and fails the person holding the phone.

The numbers, and where they come from

In May 2023, majority staff of the US Senate Committee on Finance ran a secret shopper study. They pulled directories from 12 plans across 6 states and placed 120 calls to listed, in-network mental health providers, posing as someone trying to book an appointment for an older relative with depression.

• 33 percent of the listings were inaccurate, had non-working numbers, or never returned a call.
• Staff were able to secure an appointment 18 percent of the time.
• Results ranged widely by state, which tells you this is a plan and market behavior rather than a law of nature.

Two caveats, because the number deserves them. This was a staff study, not a peer-reviewed trial, and 120 calls is a small sample drawn from a specific slice of plans. It shouldn't be quoted as a precise national rate. What it does establish, and what other work supports, is that the gap between the directory and reality is large and not a rounding error.

Why directories rot

Nobody sits down and builds a fake network. It degrades, because every incentive points that way.

Clinicians leave panels quietly. Nobody's job is to notice. Updating a directory costs the plan money and produces nothing the plan is measured on, while a longer list makes the network look stronger to regulators and to prospective members. Psychiatrists in particular churn off panels faster than most specialties, for reasons covered in cash pay versus insurance and the economics of insurance-free practice. And the clinician who stays on the panel with a closed schedule has no reason to volunteer that fact to anyone.

The result is a slow accumulation of names that used to be true.

The shortage that isn't only a shortage

This reframes something. We talk about the psychiatrist shortage as a supply problem, and by the HRSA workforce numbers it genuinely is one. But a portion of what patients experience as a shortage isn't an absence of psychiatrists. It's an absence of reachable psychiatrists inside the network they were sold.

That distinction changes the policy answer. If access fails because there aren't enough clinicians, you train more. If it fails because the ones who exist aren't findable or aren't taking the insurance, training more does very little, which is the argument in we can't train our way out of the shortage. Both failures are real. They don't have the same fix.

What would actually fix it

Directory accuracy is a solvable problem, which is what makes it infuriating. Require verification on a short cycle and penalize inaccuracy, and directories get accurate, because right now the cost of a wrong listing falls entirely on the patient and never on the plan. Move the burden and the behavior moves.

The deeper fix is the one nobody wants to fund: make the panel worth joining. Clinicians don't leave networks capriciously. They leave when the reimbursement, the administrative load, and the denial rate stop being worth it. A directory is a symptom. The panel economics are the disease, and they connect directly to whether parity is actually enforced.