The Ghost Network Scandal Continues: Directories Promise ABA Access but Families Still Struggle

The Federal Data

WASHINGTON, D.C. – In October 2025, the HHS Office of Inspector General published a data brief that quantified what families navigating Medicaid behavioral health have long suspected: the provider directories are unreliable. The OIG found that 72% of behavioral health clinicians listed in Medicare Advantage or Medicaid managed care plan directories were not participating providers and should not have been included. The finding was reported by the American Psychiatric Association’s Psychiatric News as evidence that “ghost networks in behavioral health are pervasive throughout the medical insurance industry.” In Maricopa County, Arizona, the same county where 11 families later filed a class action over ABA access, the OIG documented a 55% inactivity rate among behavioral health providers listed in Medicare Advantage directories and a 28% inactivity rate in Medicaid managed care directories.

The term “ghost network” describes a provider directory that lists clinicians who are not accepting new patients, are not accepting the plan’s insurance, have closed their practice, or cannot provide the services listed. The directory creates the appearance of adequate access. The reality, when a family calls the numbers, is a cascade of dead ends. The Senate Finance Committee documented this pattern in a May 2023 secret shopper study: of 120 mental health provider listings contacted by phone across 12 plans in 6 states, 33% were inaccurate, returned non-working numbers, or went unanswered. The Government Accountability Office reported in 2022 that CMS does little to verify the accuracy of provider information in managed care directories, despite known widespread inaccuracies.

Atlas Systems’ 2025 Member Experience Monitor found that 58% of provider directory users have encountered incorrect information. Eighty percent of those who found errors said the experience made them trust their health plan less. Only 15% of members who found directory errors reported it happening just once; 78% found errors more than once. For families seeking ABA therapy for a child with autism, the consequences of directory errors are particularly severe. ABA requires a consistent therapeutic relationship, established over months of daily or near-daily sessions. A family that spends weeks calling providers who turn out to be unavailable loses both time and developmental opportunity for their child.

The HHS Office of Inspector General found that 72% of behavioral health clinicians listed in Medicare Advantage or Medicaid managed care directories were not participating providers. In Maricopa County, Arizona, the inactivity rate was 55% for Medicare Advantage and 28% for Medicaid managed care.

The Arizona ABA Connection

The ghost network problem became central to Arizona’s ABA access crisis when attorney Michael Easley Jr., representing 11 families in a class action against AHCCCS, told the Arizona Mirror that some managed care organizations intentionally make it difficult for enrollees to access care. Easley described how MCOs list providers in their directories who have no openings, do not accept Medicaid, are closed, or cannot provide the services listed. His structural argument connected ghost networks to the capitated payment model: “The more therapies provided to each client, the less money the managed care organization makes, and ABA therapy is expensive.”

The argument directly challenged AHCCCS’s defense of the Mercy Care contract terminations. When Mercy Care dropped Action Behavior Centers and Centria Healthcare from its network, AHCCCS argued in court filings that Mercy Care’s “remaining network of over 70 ABA providers” had capacity for more than 1,000 members. The families’ attorneys responded that the 70-plus figure was misleading: many of the listed providers had year-long waitlists, were geographically inaccessible, did not provide the same intensity of services, or were functionally unavailable. If the OIG’s behavioral health inactivity rates apply to ABA directories in Arizona, a network that lists 70 providers might contain as few as 50 who are actually active, and far fewer who have openings for new clients requiring 20 to 40 hours per week of therapy.

The capitated payment model is the structural engine behind ghost networks. Under capitation, Medicaid managed care organizations receive a fixed monthly payment per enrollee. Every service delivered reduces the MCO’s margin. In this structure, the MCO’s financial interest is to minimize the volume and cost of services. A ghost network serves that interest: it allows the MCO to satisfy directory-based network adequacy requirements on paper while limiting the number of providers who are actually available to deliver care. The providers who appear in the directory but cannot be reached create a buffer between the MCO’s contractual obligation to maintain a network and the actual cost of delivering services through that network.

The National Enforcement Wave

The ghost network problem is not limited to Arizona or to ABA. In February 2026, New York Attorney General Letitia James announced a $2.5 million settlement with EmblemHealth over behavioral health ghost networks. A secret shopper survey conducted by the attorney general’s office found that more than 80% of behavioral health providers listed as accepting new patients were effectively unavailable. Between 2018 and 2024, more than 360 EmblemHealth customers filed complaints about directory errors. The settlement requires EmblemHealth to develop a statewide recruitment and retention plan, submit to independent monitoring, and reform its directory practices. ProPublica’s 2024 investigative series “America’s Mental Barrier” documented how the same pattern played out across multiple insurers.

In April 2025, three plan members filed a class action in New York against Carelon Behavioral Health, the behavioral health subsidiary of Elevance Health, alleging that Carelon “knowingly published an inaccurate and misleading provider directory to attract customers and create the appearance of compliance with state and federal network adequacy rules.” The plaintiffs described calling large numbers of listed providers only to find that most were not accepting their plan. A federal judge allowed the claims to proceed in April 2026. In January 2026, the American Psychiatric Association filed its own class action against EmblemHealth in federal district court, representing six individuals, including patients and psychiatrists. The APA described ghost networks as “pervasive throughout the medical insurance industry” and cited the OIG’s 72% finding as evidence of a systemic failure.

A separate lawsuit was filed against Centene, which operates in Arizona through its subsidiary Health Net, following a member’s death allegedly linked to the insurer’s ghost network. That case, reported by Healthcare Dive in June 2025, adds a dimension of patient safety to what has predominantly been framed as an access and compliance issue. Taken together, the EmblemHealth settlement, the Elevance lawsuit, the APA class action, and the Centene case represent an enforcement wave that is transforming ghost networks from an accepted industry dysfunction into an active litigation and regulatory risk.

Under capitation, every service delivered reduces the MCO’s margin. A ghost network allows the MCO to satisfy network adequacy requirements on paper while limiting the number of providers actually available to deliver care. The providers who appear in the directory but cannot be reached create a buffer between obligation and cost.

The Regulatory Response

Congress and CMS have begun building the regulatory infrastructure to address ghost networks, though the timeline for full enforcement extends years into the future. The Consolidated Appropriations Act of 2023 revised and codified provider directory requirements to address “phantom” provider networks. The 2024 Medicaid Managed Care Final Rule, codified at 42 CFR 438.68, introduced appointment wait time standards for the first time and mandated annual secret shopper surveys to test the accuracy of provider directories. States must be notified of directory errors within three business days of identification. Effective July 1, 2025, Medicaid MCO directories must be searchable and must include information about mental health and substance use disorder providers.

For Medicare Advantage, CMS finalized a rule requiring plans to submit provider directory data directly to the agency, beginning in 2026 for an interim solution and transitioning to plan-sourced data for 2027. Plans must update directory information within 30 days of becoming aware of a change and attest to accuracy. The Lown Institute, analyzing these changes in February 2026, noted that while they are “encouraging,” CMS has historically imposed few enforcement consequences for network adequacy failures. KFF found that Medicare Advantage plans include just 48% of doctors who accept traditional Medicare. Until enforcement matches the scale of the regulatory framework, the gap between directory listings and actual access will persist.

What This Means for ABA

The ABA sector is uniquely vulnerable to ghost network harm for several reasons. First, the supply of BCBAs is severely constrained: 74,286 BCBA-level clinicians nationally for an estimated 2.9 million children and young adults with autism. Half of U.S. counties have no BCBA. When a managed care directory lists ABA providers who are at capacity or not accepting new Medicaid patients, the gap between the listed network and the available network is wider than in most other specialties because the underlying supply is so thin. Second, ABA therapy requires high-frequency, high-intensity contact: 20 to 40 hours per week for comprehensive programs. A provider who technically has a license and an office but cannot accommodate a new client for 30 hours per week is functionally unavailable for the families who need that level of care. Third, continuity matters more in ABA than in many other therapeutic relationships. A child with autism who has spent months building rapport with a behavior technician and adapting to a clinical environment cannot simply transfer to another provider without significant disruption.

When AHCCCS told families that 70-plus ABA providers remained in Mercy Care’s network, and when families’ attorneys described that number as a ghost network, they were arguing about the gap between listed capacity and actual capacity. The OIG data, the EmblemHealth settlement, the Carelon lawsuit, and the Senate Finance Committee’s secret shopper study all suggest that the gap is real and that it is larger in behavioral health than in other specialties. For ABA families navigating Medicaid managed care, the directory is the first and often only tool they have to find a provider. If that directory is 28% to 72% inaccurate, depending on the market and plan, the families are not choosing among 70 providers. They are calling 70 numbers and hoping that 20 or 30 of them answer.

AT A GLANCE

SOURCES & REFERENCES