Medicaid “Ghost Networks” and the WSJ: What We Can Fix Now

If you read November’s Wall Street Journal piece on Medicaid “ghost networks,” you probably had the same reaction I did: this isn’t just a data problem, it’s a human problem. 

The article highlights what many of us inside the system already know: 

• Many providers listed as “in network” aren’t actually seeing Medicaid members 
• Some are listed at locations where they no longer practice 
• Others are misclassified entirely: Wrong specialty, wrong credentials, wrong state 
• And members, especially those on Medicaid, are the ones paying the price in time, frustration, and delayed care 

Yes, some of this stems from structural issues like clinician shortages and lower Medicaid reimbursement. Those are real and complex policy problems.

But there is also a part of this challenge that is within our control: The accuracy, timeliness, and governance of provider data itself. 

If a plan, a state agency, and a provider are all operating from different, outdated versions of “truth” about where and how a clinician practices, ghost networks are almost guaranteed. 

Ghost networks are a data lifecycle problem 

What the WSJ surfaced in one article is the downstream effect of something we see every day: 

• Provider data lives in too many systems (directories, credentialing, contracting, claims, portals) 
• Those systems don’t talk to each other well 
• Updates rely on manual, one-off processes — faxes, forms, emails, spreadsheets 
• And providers are asked to repeat the same information over and over for different plans and programs 

So, directories become static snapshots of a dynamic reality. 

From my vantage point working in provider data management and credentialing, I’d summarize it this way: We don’t just need better directories. We need a better provider lifecycle—with clean, connected data from the moment a provider joins a network through every change they make. 

From ghost networks to live networks 

The good news: we actually have the ingredients to move from ghost networks to live networks. Here’s what that looks like in practice: 

1. Use live signals, not just static files. Instead of relying solely on what’s been reported in a spreadsheet or portal, plans can use real activity—claims, eligibility checks, prior auths—to see: who is actively seeing members, where they’re practicing, and whether they’re accepting new patients. That’s essentially what the WSJ did manually; the opportunity now is to operationalize that continuously. 
   • Example: Want to know if a cardiology office is accepting new patients? There are billing codes specific to new patient appointments. Check their claims submissions and see if those codes appear. That will tell you if they’re seeing new patients. 
2. Make providers partners, not data vendor. Signals from transactions are a powerful tool to alleviate these issues, but they’re just that—signals. They can tell us what’s happening at a doctor’s office, but they can’t tell us what’s about to happen. For expertise on a provider’s business, there is no substitute for the provider. 
   • Example: That new patient billing code? Who’s to say that’s not the last one they can accept for a long time? Don’t see pulmonary treatments at a given site? Maybe a pulmonary specialist starts on Monday. 
3. Treat credentialing data as the truth layer. If a clinician is credentialed as one specialty but appears in the directory as another, members pay the price. Connecting credentialing and directory workflows ensures members see the correct specialty, taxonomy, and credentials, and it means states and regulators have more confidence in network adequacy reporting.

This is where solutions like Availity’s Provider Lifecycle Solutions come in—connecting those pieces so that payers, providers, and regulators are all working from the same, live source of truth. 

What health plans and Medicaid programs can do now 

You don’t have to wait for a new regulation or the next news cycle to start closing the gap between “in network” and “in real life.” A few practical steps: 

• Elevate provider data to strategic infrastructure: Treat it the way you treat claims or clinical data – governed, monitored, and continuously improved, not just “IT plumbing” for directories. 
• Break the silos inside your own organization: Connect directories, credentialing, contracting, and claims systems so changes flow across the lifecycle instead of getting stuck in one department. 
• Lean into shared, multi-payer approaches: Asking every provider to maintain the same changes with every plan is a recipe for fatigue and inaccuracy. Multi-payer, shared-data models lower the burden and improve quality. 
• Measure what’s real, not just what’s reported: Incorporate claims and other live signals into how you monitor network performance and adequacy, especially for Medicaid.

No technology alone can solve provider shortages or reimbursement challenges. But we can make sure that when a member pulls up a directory or calls a plan, the information they get reflects the world as it is – not as it was 18 months ago. 

If you’re working in Medicaid, network management, provider relations, or credentialing and this article hit close to home, I’d love to compare notes on how you’re tackling ghost networks today – and where a more connected provider lifecycle could help.