Ghost network refers to a form ofhealthcareinsurance fraud whereproviders are listed as in ahealth insurance plan, but are unable to provide care. These ghost providers may no longer be eligible to practice, may have retired, may no longer accept new patients, may not actually part of the network, or may not exist. The inclusion of ghost providers may be intentional to exaggerate plan availability to encourage enrollment and falsely meet healthcarenetwork adequacy.[1]
Ghost networks can negatively affect the quality of service received by plan participants and the delayed care may negatively impact patients.[2]
Health insurance carriers may decline to make up-to-date directories of participating providers available online, and instead mail directories to delay and decrease utilization.[3] Network accuracy is not enforced at the federal level, but several states have passed legislation to address the issue.[4][5]
Ghost networks are prevalent for mental health providers in the US.[6]
Types offraud | |
|---|---|
| Business-related | |
| Family-related | |
| Financial-related | |
| Food-related | |
| Government-related | |
| Healthcare | |
| Other types | |
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