Improve Mental Health Access with Accurate Provider Data

Objectives: Access to mental health services has been shown to be particularly inadequate, with limited understanding of the efficacy of existing network adequacy regulations. State and federal regulations mandate insurance carriers to submit regulatory filings to help maintain network adequacy compliance, but the accuracy of these data remains unassessed.

Study Design: We employed a secret shopper survey to verify regulatory filings and assess the congruence between the filings and provider directory listings as well as appointment availability and wait time for 8306 mental health counselors submitted by all carriers participating in Pennsylvania’s Affordable Care Act (ACA) Marketplace for plan year 2024.

Methods: Descriptive analyses, with tests of proportion and t tests to assess differences between carriers and between adult and pediatric provider specialties.

Results: A total of 19.9% of filed regulatory listings (n = 1649) were not present in consumer-facing provider directories, and only 35.3% of filed listings (n = 2928) fully matched provider directory entries. Of the 2152 provider listings we were able to verify fully via secret shopper calls, 65.2% (n = 1404) exhibited at least 1 inaccuracy. Inaccurate phone number was the most common issue (56.6%; n = 1219). Appointments were available for only 321 of the 2152 providers (14.9%), with a mean of 33.2 days lapsed between call and scheduled appointment time. Although we identified substantial differences in appointment wait times by carrier, we found no difference between adult and pediatric providers.

Conclusions: ACA network adequacy assessments that rely on carrier regulatory filings and/or consumer-facing directories substantially overestimated provider availability and access to mental health services.

Am J Manag Care. 2025;31(9):In Press

Using a large secret shopper survey of mental health counselors available in Pennsylvania’s Affordable Care Act Marketplace, we found the following:

Carrier regulatory filings often did not align with consumer-facing provider directories;

Carrier regulatory filings were often inaccurate; and

Few appointments were available, and wait times averaged more than 33 days.

Our findings add to concerns about timely access to mental health services as well as the use of regulatory and consumer directories to assess and monitor network adequacy.

Despite landmark policy changes to cover mental health services on par with medical and surgical benefits, insured consumers continue to face barriers in accessing mental health services.1-3 Consumers are more likely to seek care outside their insurance networks for mental health concerns compared with physical health concerns, leading to out-of-pocket costs, care delays, or forgone treatment.4-6 In light of these gaps, recent federal and state network adequacy regulations have sought to improve monitoring and oversight of consumer access to health care, including mental health services.7-11 Regulators across all markets assess network adequacy, in part, by requiring insurance carriers to file detailed data, often yearly, of their provider networks, including the name, address, and specialty of each participating provider.8,12

One important contributor to the access challenges facing mental health consumers may be that neither existing regulatory filings nor provider directories reflect real-world provider availability and accessibility. That is, the data upon which network adequacy assessments are generated may not accurately capture consumer access challenges. Carriers face substantial logistical and administrative difficulties in monitoring their provider networks,2,5,13-16 with data management challenged by frequent organizational or workforce changes.17 Given the current regulatory environment, carriers also have few incentives to ensure a large degree of accuracy in their filings.7,18 Thus, data inconsistencies may disguise the true extent of network inadequacies and render current oversight efforts ineffective.7,19

To our knowledge, however, no prior study has directly evaluated the accuracy of network regulatory filings. To assess this important source of network information and whether consumers can access care in a timely manner, we first compared these filings with online consumer-facing provider directories (hereafter referred to as provider directories) for all Pennsylvania Affordable Care Act (ACA) Marketplace carriers in plan year (PY) 2024.12 We subsequently verified the filings via a secret shopper survey to assess their accuracy as well as appointment availability and wait times.

Carriers participating in the ACA Marketplaces are required to “maintain a network that is sufficient in number and types of providers.”12 To ensure compliance with all regulatory requirements and standards, carriers must provide an overview of their networks across markets and states.8,20 In Pennsylvania, ACA carriers are required to submit this information yearly to the Pennsylvania Insurance Department (PID) to obtain network approval, with subsequent quarterly, more limited submission for monitoring purposes.12 The files are subsequently analyzed by a PID network vendor for compliance with all federal and state adequacy standards. The yearly submission also contains a narrative that outlines access gaps and efforts to mitigate these gaps.

We obtained the annual filings for PY 2024 (submitted in May 2023) from the PID for outpatient mental health counselors, including licensed clinical social workers, licensed marriage and family therapists, and mental health counselors for both adults and children.21 Carriers submit unique files for adult and pediatric providers. We identified 11,685 adult providers and 19,423 pediatric providers among 31,108 total listings for all carriers (Ambetter Health, Capital BlueCross, Cigna, Geisinger, Highmark BlueCross BlueShield, Independence Blue Cross, Oscar Health, UPMC). Providers listed as seeing both pediatric and adult consumers were counted twice.

Paid student research assistants (callers) were randomly assigned a provider listing. Online provider directories for the respective carriers were used to search for each provider by name. If a given provider was not located, another provider was assigned. For provider listings that were successfully identified in online directories, available contact information (street, city, state, zip code, and phone number) was compared against PID filings. Callers then proceeded to contact the provider, adopting a scripted role as an individual seeking an appointment for a family member or close friend. Callers sought to verify network participation, specialty, and phone numbers (encountering cases such as the number being disconnected, only a fax number was reached, a place other than a medical office was reached, or the provider never worked in the office) based on data from the PID filings.2,22-24 To maintain callers’ disguise as real shoppers, calls ended once the first inaccuracy was identified. If they connected with an accurately listed provider, callers also asked for the next available appointment and recorded the appointment date without scheduling it. Overall, callers searched for 8306 mental health counselors and sought to contact the 6657 individuals they were able to match between PID filings and online provider directories (eAppendix 1 [eAppendices available at ajmc.com]). Data collection and verification of the annual network adequacy filings occurred from August 16, 2023, to February 27, 2024.

We performed descriptive statistics comparing match rates between PID filings and provider directory listings. For sensitivity analyses, we also reanalyzed all data accounting for the passage of time (omitted). We compared findings by adult and pediatric provider types and across carriers using tests of proportion and t tests, as appropriate. The study was approved by the Texas A&M institutional review board.

Accuracy of Carriers’ PID Filings vs Provider Directory Information

Resource constraints allowed us to randomly survey 8306 providers (3170 adult and 5136 pediatric) from the overall population of 31,108 providers (26.7%). The sample size exceeded the requirements for a margin of error equal to or less than 1% with a 95% confidence level. Of these 8306 providers, we identified 6657 providers (80.1%) in the carriers’ corresponding online provider directories (eAppendix 2). Match rates for listings between PID filings (eAppendix 3) and online directories ranged from a low of 47.4% (292 of 616) for carrier D to a high of 88.3% (1207 of 1367) for carrier F (P < .001). Match rates were higher for pediatric (82.7%) than for adult (76.0%; P < .001) providers.