Terry Gerton You’ve got a couple of really important to reports out that we want to dive into because Medicaid covers a large share of births in the United States and states rely heavily on managed care. But you started to look at how maternal care is playing out in that system. What prompted the investigation here?

Laura Kordish We wanted to better understand how accurate the provider information that states and Medicaid enrollees rely on is. And we looked at the information patients use to find maternal health care providers and make appointments. And we also looked at the information that Medicaid managed care plans give to states to oversee access. And we looked at this now because the U.S. is in the midst of a maternal health crisis with worse pregnancy outcomes than any other high-income country. And, you know, as you noted, Medicaid covers a big share of those births, over 40 percent, and most of those are managed care. So we thought it was important to review because if enrollees can’t reliably find providers, it could prevent them from getting essential prenatal and postpartum care.

Terry Gerton When you looked at the list that the providers, the insurance providers actually give to states, what did you find? Were they accurate?

Laura Kordish Not very accurate, one in four of the network providers on the list that plans submit were not actually in network. In other words, on paper, the managed care plans may have met the requirement to have adequate providers, but in reality, nearly a quarter were not in network, and we refer to these as ghost providers because they’re not actually available to pregnant enrollees for appointments. In addition, another 26% of listed providers didn’t have any accurate phone numbers. So overall, the list from plans had significant errors that can undermine oversight of access and ultimately inhibit patient care.

Terry Gerton So there’s some real ramifications from those inaccuracies. Walk us through how this is supposed to work both from how the states use these lists and how patients are supposed to use these list.

Laura Kordish Yeah, states are responsible for ensuring that patients and Medicaid managed care plans have access to care. And one way states oversee this is by checking to see if plans have enough providers in their networks. States compare network lists from plans to their network adequacy standards. So for example, state standards may require a certain number of OBGYN providers for every 1,000 enrollees. Or state standards may require that plans have one maternal health provider within a certain distance, say 30 miles of each enrollee. So it’s important that these lists from plans are correct.

Terry Gerton And how does a patient use these lists.

Laura Kordish So patients use these lists to find the providers that are available to them. And we looked at the same information that patients use to find providers, and we found a number of problems. For example, we found ghost providers, providers who are listed are not actually available. And you can imagine how frustrating that is. We also found providers that were available but not listed. In this case, a patient might be having trouble. Finding a provider and there is someone actually available to them but they don’t know about it. And then in other cases the providers were right but the contact information was wrong. So for a pregnant woman needing time sensitive care these problems aren’t just annoying. They can be serious obstacles to care and cost precious time and ultimately lead to worse outcomes for moms and babies.

Terry Gerton Laura Kordish is the Regional Inspector General for Evaluation and Inspections at the Department of Health and Human Services Office of the Inspector General. Laura, those are really important outcomes. I mean, when we talk about, well, the data wasn’t complete or wasn’t accurate, it sounds very dry. But this gets to real personal impact. It also has managerial impact on the program. If the lists are wrong, what does that do to the oversight practices? What can providers or the states no longer see or verify?

Laura Kordish Yeah, inaccurate lists undermine state’s oversight of network adequacy. States use these lists to compare against requirements and if the lists are faulty, states might draw the wrong conclusions about whether plans are meeting the requirements. For example, if the list from the managed care plan on paper is more robust than in reality, that might mask a shortage that the state would wanna know about. And if the contact information is wrong, it’s hard to verify providers on the list. So those are some ways that inaccurate data can undermine oversight by masking problems and making it harder for patients to figure out where they will get needed maternal healthcare.

Terry Gerton We also hear a lot of concern about fraud in the Medicaid space. Are you concerned that the inaccuracies in these provider lists may be a window into Medicaid fraud?

Laura Kordish We can’t tell that from this study, but what we can say is that we found many inaccuracies with the provider information, and these inaccuracies can really undermine state oversight and interfere with patients getting needed care.

Terry Gerton Well, you did make a number of recommendations in these reports for both CMS and for the states. When you walk through those, what’s the most important change that would actually improve visibility into these networks?

Laura Kordish Most important thing is holding plans accountable for accurate provider information. And we offer ideas on how states could do this. For example, states could set their own standards for accuracy rates for provider information, they could strengthen contract language with managed care plans to reflect their expectations for accuracy. They could consider enforcement strategies like penalizing non-compliance. But at the end of the day, with billions of public dollars invested, a Medicaid enrollee shouldn’t have to guess where to find care. Accurate provider information is fundamental to making this system work.

Terry Gerton Laura, one of the recommendations in the reports is that CMS improve or strengthen its accountability measures. But what would that really require of states? Are there things that they can do right now that would improve their accuracy?

Laura Kordish One idea would be for states to use one list of providers instead of two and focus on keeping that list updated. So we found in our work that managed care companies are submitting one list to the states for oversight, and then a second list is populating the provider directories that enrollees use to find care. And we found significant errors on both lists and the lists didn’t match. So, if states wanted a quick action to help improve their oversight, one idea for them is to just use one list and keep that up to date.

Terry Gerton And do you find that the states have the capacity to manage that complexity?

Laura Kordish That’s a great question. I think you’d have to ask the states.

Terry Gerton What will the follow up for this be? I mean, this is a significant issue. As you had explained, it has a really palpable impact on maternal care. How do you follow up on something like this?

Laura Kordish Sure. So OIG follows up on all of our recommendations within six months of publications of the report. We ask the agency to provide specific actions in a timeline, then we follow up annually on status. And then we’re always evaluating topics for new work. And we do have another item in progress on our published work plan on maternal health related to reducing costs and improving outcomes for Medicaid, managed care, and enrollees diagnosed with preeclampsia. And I can forward you that information if you would like it.

Terry Gerton That would be great. And we’ll share it with our listeners as well.