'I Don't Want to Die.' He needed mental health care. He found a ghost network

https://www.npr.org/sections/shots-health-news/2024/09/21/nx-s1-5120543/mental-health-care-parity-insurance-ghost-network

by jameslk • 2 years ago

207 198 2 years ago

npr.org

dgoldstein03• 2 years ago

This is messed up. Feels ripe for a wrongful death lawsuit at the minimum, and likely some regulatory enforcement against this scam insurance

anjel3• 2 years ago

Perhaps you've never attempted to sue your once and former insurer for contract breach... You probably get the implied frustration and futility, but remember to include the impact of same on your yet-to-be treated illness.

dgoldstein03• 2 years ago

No I have not sued anyone.

But my point is now that he's gone, maybe his family could sue. Not sure that'll really fix anything though. Laws and regulations with real enforcement could though.

hgomersall• 2 years ago

I know how hard it is from that non-fiction work, The Rainmaker.

LorenPechtel5• 2 years ago

It depends on how you got your insurance.

There's a law limiting liability with employer-provided stuff to the amount in question. It wasn't that bad a law as originally intended: retirement accounts. But it also limits liability with insurance. Liability is capped at the amount of the denied claim--which means that in most cases it would cost more than the recovery.

I'm not sure what the legal situation is when there's no employer involved and you have an exchange plan.

wantsanagent• 2 years ago

I've encountered this in the Pittsburgh area with AHN. Trying to get a provider results in printed lists of outdated numbers, practices not accepting patients, etc.

Frankly I think we need to start breaking laws. A startup needs to offer straight up good care and fuck the web of infinite regulations which support America's for profit health failure.

Doctors can lose their licenses pretty easily so it's going to have to be a straight tech play. Offer as-good-as-possible care entirely outside of the medical profession. AIs are getting good enough that despite the obvious errors they make they are still better than the nothing-burger of care we get here.

dgoldstein03• 2 years ago

I don't see how the law is the problem here. The problem sounds like insurance companies that dodge their duties. We need them to be held accountable. We likely also need the general cost of doing business in healthcare to go down - which they are partly responsible for due to throwing up so many barriers for them to actually pay for anything.

bumby6• 2 years ago

Steelmanning the OP (which I’m not sure I agree with), it’s possible they are alluding to regulatory capture, implying the laws are crafted to benefit for-profit companies first and patients second.

However, I’m not sure going in the direction of less regulation would help. It’s like saying “The for-profit healthcare companies have too much power, so let’s just give them more power.”

akira2501• 2 years ago

We need them to be held accountable. We likely also need the general cost of doing business in healthcare to go down

These two statements are at odds with each other.

responsible for due to throwing up so many barriers

To me, it's obviously lack of competition that's the problem, you don't want to punish crappy providers, you want to subsidize new ones so the market is flooded with options.

Which can be done right after we solve the monopolization problem in health care service providers, medical equipment providers, and "pharmacy benefit managers."

xtracto5• 2 years ago

My dream project is a non-profit smart-contract based insurance system: with double blind analysis of claims by doctors who have nothing to win from approving/rejecting a specific claim, a system were there is no asshole middleman insurance racket company.

I know this tech is disliked in HN, but I am positive that it is possible build something like that, due to the "trustlessness" capabilities.

antisthenes3• 2 years ago

Frankly I think we need to start breaking laws.

Who's stopping you? I don't pay my medical bills by default, unless it's my dentist or my primary care provider.

Everyone else can go to hell until the system breaks.

bumby6• 2 years ago

Most large systems can absorb a certain level of free-loaders and remain stable by shifting that burden to other people. What you’re advocating is a collective action problem and will just make matters worse for everyone else. Unless you have a way to create a critical mass of similar behavior, it’s tantamount to a selfish action that benefits you to the expense of others.

jfengel2• 2 years ago

It's not like starting up a food truck. A health care operation is vast, and no existing providers are going to break the law and risk losing their licences.

You would need to create an entire parallel network. It would cost tens of billions, possibly hundreds.

insane_dreamer2• 2 years ago

offer straight up good care and fuck the web of infinite regulations which support America's for profit health failur

they'd get immediately sued out of existence by the large vested interests

keybored• 2 years ago

I almost teared up.

_dark_matter_• 2 years ago

I did as well. My cousin passed away in his early 30s from alcoholism - this story hit close to home.

xyst• 2 years ago

It’s beating a dead horse at this point, but private health insurance is quite possibly the worst middleman I have ever dealt with.

They not only make the patients life worse but the doctors and hospitals as well. Dealing with insurance means small practices need a dedicated office staff to file the right paperwork and get paid for each patient visit.

yieldcrv5• 2 years ago

I’m curious about why it wasn’t considered to switch insurers, the article has do many details on many processes and I felt this one was not investigated

It’s definitely hard to cancel them and the expense adds up to pay premiums for two

Was it a possibility?

siliconwrath2• 2 years ago

I obviously don’t know the specifics, but US healthcare plans only let you change during specific enrollment periods or qualifying life events. It’s possible he wasn’t able to.

Additionally, it sounds like he picked what appeared to be the best rated plan available to him on the market. Others may have been even worse or prohibitively expensive.

mystified5016• 2 years ago

You have the choice of a couple of large companies that will deny every claim always for any reason, and a few smaller players who no doctor in your area has heard of or can accept payment from.

So yeah, you have a 'choice'

geraldwhen• 2 years ago

Or pay cash for therapy. Or have the parent pay cash for therapy. Options existed, but there are none now.

maxverse• 2 years ago

Hands down the worst and most stressful part of living in America, and the only reason I - a child of immigrants who are grateful to have built a life here - would consider moving somewhere else

GFischer• 2 years ago

It was one of the biggest considerations that made me decide against moving to the USA.

One of my coworkers took advantage of the L1 Visa (which I can still qualify for) and she ended up moving back to my home country Uruguay even though she made 50% higher salary in USA.

She did live some of the worst stuff in USA like Texas electricity failures, 20.000 dollar healthcare bills, etc.

Der_Einzige• 2 years ago

Integrated providers, such as Kaiser Permanente, have far fewer issues related to the problems brought up in this article compared to most others.

Nothing like this would ever happen in a Kaiser hospital.

slantedview• 2 years ago

Kaiser had its own very sordid history of denying people mental healthcare which has led to deaths, fines by the state of California, and new legislation.

spease• 2 years ago

Nothing like this would ever happen in a Kaiser hospital.

Kaiser’s mental health services were so bad that their providers went on strike a couple years ago. They’re paid a fraction of what they could make in private practice.

https://www.healthcaredive.com/news/kaiser-strike-mental-hea...

Analemma_• 2 years ago

I don't think you know Kaiser very well. Kaiser's vertical integration is really good at some things, but the other edge of this sword is that if you need treatment in a specialty they're bad at, you're fucked: there's nowhere else to go because getting out-of-network care with Kaiser is nigh-impossible. And mental health is infamously one of the things Kaiser is very bad at. Their mental health coverage is so inadequate that if I was choosing between insurance providers I'd pick a different one for that reason alone.

fragmede• 2 years ago

By "nothing", are you referring to the incident in Santa Rosa in 2015?

https://nuhw.org/therapists-demand-action-in-response-to-tra...

Or the one in San Diego in 2021.

https://www.sandiegouniontribune.com/2021/03/31/kaiser-patie... (https://archive.is/wF1bD)

Or maybe you're referring to the incident in Santa Clara in 2022.

https://www.medpagetoday.com/nursing/nursing/98534

Of course, those incidents aren't like the one mentioned in the article. The ones I linked are just a gross failure of Kaiser's mental health resources leading to three people's deaths instead. At least they didn't have to deal with a ghost insurance network though!

jimbob45• 2 years ago

Works well for me and I’m not even wealthy. I get the feeling that the universal healthcare advocates have convinced everyone that things are far worse than they actually are.

betaby• 2 years ago

Canada got worst combination of private/public, not-really-a-singly-payer, not that universal care.

incangold• 2 years ago

“Works on my machine, ticket closed”

treyd• 2 years ago

I just had an antibiotic prescription denied because my insurance company thought I had a refill in 5 days, despite the last time I was prescribed it was as a one-off course, 8 years, and 3 insurance companies ago.

insane_dreamer2• 2 years ago

nice sample size of 1

olalonde5• 2 years ago

The problem is that it's not a free market either thanks to medical licensing laws, monopoly control over the accreditation of U.S. medical schools, etc. The supply of doctors was even once artificially limited as a matter of policy due to a fear that there would be a "surplus" of doctors (aka fear that doctor salaries would go down).

The Graduate Medical Education National Advisory Committee convened by the Secretary of Health and Human Services (HHS) issued a report in 1980 warning that there would be a “surplus of 70,000 physicians by 1990” if steps were not taken to bring supply and demand into balance.
This near freeze was enforced by the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA), the two sponsors of the Liaison Committee on Medical Education, which is the sole accreditor of allopathic medical schools recognized by the U.S. Department of Education. The decision not to expand the number of slots in U.S. allopathic medical schools remained in place until 2005, when the AAMC and AMA changed their minds from declaring an impending doctor glut to warning of a looming doctor shortage.

https://www.heritage.org/education/report/why-dont-us-medica...

xtracto5• 2 years ago

This comment reads so American.

wintermutestwin2• 2 years ago

If I could recover the cost of my time in small claims court, I’d be making a hefty sum from these parasitic insurance companies that constantly require me micromanaging their antics.

staticautomatic2• 2 years ago

In CA I wonder if a PAGA claim could be viable.

ponector3• 2 years ago

Public health insurance in other countries are not better.

For instance, I pay 10% of my income for it and in some cases queues just to start treatment are for few years. And it does not cover teeth, implants, vaccines.

If case is urgent, like a cancer, it can take 6+ month to actually start treatment due to all paperwork and queues everywhere.

weakfish• 2 years ago

Sounds like poor implementation, not a reflection on the concept. Which sucks - don’t get me wrong, that needs to be improved!

Private insurance has all the wrong incentives, and IMO profit should never be linked to the health of a human for that reason.

lostlogin• 2 years ago

What country is this?

gigatexal• 2 years ago

This could be said for all of private insurance: they've got a literal mandate to not pay out, pay out far below what is owed, or delay delay delay because what they keep is pure profit.

I wonder if for a public provider if the incentives are better.

llamaimperative10• 2 years ago

I think they are saying it of all private insurance

weaksauce• 2 years ago

I wonder if for a public provider if the incentives are better.

should be generally. the NHS in england was viewed more favorably than the queen and they loved the queen.

SkyPuncher• 2 years ago

My wife is a doctor and dealing with insurance is one of the worst parts of the day.

Far too often, she knows that a certain treatment plan is going to be the only and most effective plan for a patient. However, insurance will require her to exhaust several other options first.

It seems the hope is enough patients give up on treatment that they never actually seek the proper care. They'll just get chucked the "cheap" option again in the future.

_DeadFred_2• 2 years ago

I recently had to juggle 'do I pay out of pocket for this skin cancer surgery and save $600 on the $3000 total, or use insurance so that what I pay goes towards my deductible (would have fulfilled 30% of my deductible for the year). It was better to pay out of pocket.

In the last 30 years we went from affordable ambulances and insurance that worked to people too scared to use ambulances and insurance that our doctors encourage us not to use. Glad we are letting the free market work it's magic. Thankfully the market worked in our small town, the ambulance company went broke and we joined together as a community and now have county services that are not only better but much much cheaper and don't see peoples' emergencies as a profit center for some located elsewhere mega-corp. Weird how inefficient small town hick local government can now make work (and work better) what mega corp for profit 'big brains' couldn't.

Side note: USE SUNSCREEN PEOPLE! I wish I could go back and slap dumb 'too cool for sunscreen' Santa Cruz surfer kid me.

cat5e2• 2 years ago

Another Santa Cruz loc

GenerWork• 2 years ago

In the last 30 years we went from affordable ambulances and insurance that worked to people too scared to use ambulances and insurance that our doctors encourage us not to use. Glad we are letting the free market work it's magic.

The healthcare market was arguably freer 30 years ago than it is today.

madaxe_again• 2 years ago

It’s crazy that you put up with it.

Me, in Europe - I need healthcare, I go wherever I want, public or private. Public is free and good, but usually you have to wait a few weeks or months for non-critical care, and private can usually see you tomorrow. My insurance will cover it, no question - everyone is in network with everyone, and I’ve yet to find an exception. I pay €600 a year, and it covers all the root canals and colonoscopies I can handle. No copay. No excess, except on dentistry, which is like €25.

Scrapemist• 2 years ago

Where?

golergka5• 2 years ago

Keep in mind that there are different kinds of private health insurance, and american system is one of many. I live in Argentina right now. I pay about $150 per month for insurance (which is pretty expensive by local standards). They operate their own hospital, which is about 15 minutes from my home by car. I buy medicine with 50% discount, which already makes the insurance pay for itself. I don't have to search for doctors, I just open an app (or website, or call them) and make an appointment, almost all of them work in the same hospital building. My girlfriend had to use an ambulance, and now is prepping for surgery — of course, all of that is completely covered. Oh, and all the doctors give your their email or WhatsApp so you can follow up and ask them stuff anytime.

I lived in Russia before, and I've had even better experience. I don't remember how much I paid (on the same order of magnitude), but home visits costed me may be around $20 a pop. (Personally, I'm buffled why more health systems around the globe don't have home visits, I'd gladly pay a reasonable extra fee). I've also used private health insurance subscription when I lived in Israel and had to see doctors in Turkey, Georgia, Serbia and Peru, paying out of pocket; in all these instances, prices were reasonable and the whole system very nice to interact with. For instance, in Georgia, my ex had to ride an ambulance and spend week in a hospital. The whole thing cost me around $300 out of pocket.

Anyway, in any of these systems where I had a subscription, I've never had to pay and then file a claim; doctors were employees of the organisation that I paid my insurance to.

Public health insurance, on the other hand, have always been an abysmal experience, with doctors and nurses not giving f about you. It was more expensive, too: you had to bribe people so that they actually did their jobs, and it didn't improve their attitude much. Nobody in that system has any incentives to help you. And, of course, it's much more expensive in the end.

moffkalast• 2 years ago

The horse is only dead because it didn't have the cash to pay the out of pocket, so it died from a preventable disease. And even if it had the cash, the lines are so long it would've died waiting instead.

jabroni_salad• 2 years ago

I need to see a doctor about once a quarter for an ongoing issue and ended up switching to a DPC doctor. I pay a subscription out of pocket and extras are a flat rate menu, and they simply do not take insurance. However, it's been way cheaper overall and I have had exactly zero phone calls aside from setting appointments. No billing issues, no surprises, no middlemen, no problems. Oh, and I can have an appointment as soon as this week if I need one. No 8 month runaround just to get a referral.

The reason it works is because the doctors do not have to staff a billing department. the office runs like a '2 pizza team.' Just delete bureaucracy, it isn't helping us.

xtracto5• 2 years ago

It's because it's a strsight full blown scam. And it's accepted by society... terrible.

The only for profit business where you pay the company to give you a "service". But the company's main objective is to do EVERYTHING in their power to AVOID giving you the service. They will spend $100,000 to avoid covering g your $100,001 claim; that's $1 to their shareholders, which is what matters to a Corp ultimately.

Insurance business is a scam.

0xcde4c3db3• 2 years ago

I feel like the problem is that it's set up as a virtuously adversarial system where everyone is expected to strenuously advocate for their side's interests and find the best possible compromise, but nobody can afford to give enough of a shit to actually put up a fight, so it just turns into an infinite recursion of lazy fake-out maneuvers.

yieldcrv5• 2 years ago

what good another detox would do if it didn’t help him combat the root causes of his addiction through therapy

that’s how I feel about suicide hotlines and the random placement of suggesting people call them

None4U• 2 years ago

People are not going to therapy if they're dead, and those hotlines are for helping people find local resources

yieldcrv5• 2 years ago

Yeah and I acknowledge now that a large subset of suicides are totally impulsive, so any momentary disruption of the thought process is enough

I think for a different subset that none of the resources are fixing the underlying stressor or interest in ending self preservation

EMM_3862• 2 years ago

I've never heard of them.

Then I read the bring in more revenue then "Disney, FedEx or PepsiCo".

Wait, what? Oh, right, subsidaries.

And, of course, a giant in Medicare Advantage.

That company sounds ... very bad and needs to start doing what they are supposed to be doing and stop playing games. People are looking for help and they are looking for ... well, how to squeeze out more money I suppose.

"You need psychiatric care? Sorry, we're a bit busy trying to make more money. Priorities and all."

"Someone died due to our lack of caring about any of that? Sorry to hear that. Listen, gotta go. (click)"

Sue them into the ground.

aziaziazi• 2 years ago

bring in more revenue then "Disney, FedEx or PepsiCo".
Sue them into the ground

Good luck with that :-)

EMM_3862• 2 years ago

True, they are too big and have their tentacles in too many things to make them go away.

However, when you are dealing with people who are supposed to be helping people, and they are staring at how much money is currently coming instead, just do what needs to be done.

Any single law they broke? Sue them.

People are asking for serious help, and they aren't helping them. And people are dying. That is beyond unaccepable.

I hate these types of companies.

It's like the companies that buy the land under hospitals, make them pay to stay on what is no longer their land, squeeze out as much as they can, bankrupt the hospital, and do it again to another one.

Especially brutal when they do that to rural hospitals where now patients are pretty far from the other one still standing.

I have a very strong dislike for any companies in that category. The people don't matter, as long as we can extract the money, we're going to do it. Greed on steroids.

lotsofpulp• 2 years ago

I don’t think the article is right.

One of the 25 largest corporations in America, Centene brings in more revenue than Disney, FedEx or PepsiCo, but it is less known because its hundreds of subsidiaries use different names.

https://companiesmarketcap.com/largest-companies-by-revenue/

By what measure is Centene one of the US’s 25 largest corporations? Its way down at #519 in global market cap rankings, which means it is nowhere near top 25 in the US by market cap. It has $157B in revenue, so maybe that gets it close to top 25, though I still doubt it. It has less than 70k employees, which is not near top 25 either. And there are 5 other managed care organizations (aka health insurers) doing more business than Centene (UNH, Elevance, CVS, Cigna, and Humana).

It has miniscule profit margins (1.56%) because it is paying out almost all of its revenue to healthcare providers (90% medical loss ratio).

https://www.macrotrends.net/stocks/charts/CNC/centene/profit...

https://www.healthcaredive.com/news/centene-medicaid-redeter...

If this business approved more claims or paid more for the claims, it would either go out of business or become a charity. Or it would have to increase premiums.

s0rta• 2 years ago

It's 25th on the fortune 500 list

nathannecro• 2 years ago

It's because the article uses a different source than you for total revenue. If you look at the wiki page titled: "List of largest companies in the United States by revenue" [1], it lists Centene as 22nd with a slightly outdated ~$154B in revenue.

You should know the author was referencing American companies because your second line of your post reads, "One of the 25 largest corporations in America, Centene brings in more revenue...". If you look at your 'Companies Market Cap' site, you'll actually see that it includes a global set of corporations including, but not limited to, Saudi Aramco (KSA), Sinopec (CN), Petro China (CN), Volkswagen (DE), China State Engineering (CN),Toyota (JPN), JBS (BRA) etc. And those were the only ones I saw without scrolling.

I have issues with the way that author wrote her article, but I have even more of an issue with commenters like you who don't actually take the time to read or comprehend the matter at hand. You just come into a comment section with the intention of trying to prove your preconceived perspective.

The point of this article, if it's not clear, is that certain health insurers do not do a good job advocating for their insureds and do not fulfil their end of the contract. In this scenario, it seems like one could make a good argument that this lead to the death of a young man wrestling with alcoholism. It's obvious, if you read the other comments here, that the real story are the sweeping complaints of the private healthcare system in the US in general as many others seem to have had similar issues.

I'm not sure what exactly their NPM has to do with this discussion. Other, seemingly better insurers (both larger in scale and fewer complaints by customers) post margins that are more than double of Centene so it seems like Centene should take your advice and either go out of business or do a better job running their existing business.

1: https://en.wikipedia.org/wiki/List_of_largest_companies_in_t...

olalonde5• 2 years ago

Health insurance in the US sounds like such a scam. Is it not possible to pay for a psychiatrist directly or to renew prescriptions without seeing one?

wepple• 2 years ago

The former, yes, but they’re far more expensive. The latter, kind-of. You have to have regular check-ins, dependent on the type of medication

olalonde5• 2 years ago

It's crazy that you can't get a prescription for under 379$. Something is seriously broken with that system. I'm pretty sure I could get one for 1/10 that price where I live, without insurance.

NeuroCoder2• 2 years ago

As far as psychiatric health goes, its highly variable. I have a friend that I talked to last night that is working with Medicaid to revamp how they bill this kind of stuff because a lot of it is rejected by insurance since it doesn't fit within a clearly covered area. Getting small areas or sustainable coverage established like this can sometimes be a path forward to broader adoption. But that's still pretty optimistic thinking

Trasmatta• 2 years ago

I'm paying $250 per week out of pocket for a therapist in NYC.

indrora• 2 years ago

on insurance, the number is $400/session. off insurance, the number is $1200/session.

I can think of a lot better things to spend $14k a year on.

olalonde5• 2 years ago

That is the equivalent of a multi million $ yearly income for the psychiatrist. That's insane. Why aren't there more people getting into this profession? In Turkey, you could have a private psychiatrist working for you full time for $14k...

Bengalilol• 2 years ago

This is so bad : we can measure a country's strength by its weakest link. There are some major loopholes here.

knodi1234• 2 years ago

I've dealt with ghost networks too, with BCBS of CA. They provide you a directory with a thousand options, and I was already planning to go with the first provider that would have me. Had to call 15 before I got one that wasn't out of business, not accepting new patients, or not actually accepting the provider that gave me their number. So I can only assume that roughly 6% of their providers are actually real.

ipaddr2• 2 years ago

I wouldn't assume based on your sample. Most people start at the top so more of those would be filled. Businesses that add AAA to their name to appear at the top of the yellow pages are more likely to close.

knodi1234• 2 years ago

It's not a phone book. The search results were based on distance from my exact address.

robodan• 2 years ago

I assume BCBS is Blue Cross Blue Shield; which is one of the largest insurers.

Can I ask how big is the city you live in (or near)? It seems like big cities have options, but small towns starve for medical help.

knodi1234• 2 years ago

It's a capital city. In the end, there were options. Their directory had 200 providers, so even with that dismal accuracy, I bet could even find another provider if I didn't like my current one. I'm just providing supporting anecdata about how provider directories are vastly inflated with unusable results.

the-alchemist• 2 years ago

Had a similar problem with Aetna in NJ. I thought my situation was unique

theGnuMe2• 2 years ago

There is definitely a need for provider matching services. This could be something a YC startup could and should take on. Honestly, I was a bit hesitant to think AI could help but now I think it's a needed way forward. That and insurers need to be held to account.

Apocryphon7• 2 years ago

Not to get too ideological, but libertarian proponents tend to claim that businesses with poor service will just naturally be outcompeted. Those who go as far as to suggest that fraud need not be prosecuted by statist regulation will say that dishonest companies will have bad reputations and customers will naturally not patronize them.

Makes me wonder what trying to build such a reputation system would look in practice. Consumer Reports manages to hang on as a publication but not everyone consults it, and there are so many more review sites these days of varying quality, impacted by AI/outsourced copywriting.

And when you deal with an industry as dominated by a few monolithic oligopolies like health insurance or phone service- what is more bad publicity going to do to AT&T? You can’t even boycott that, especially when they lock in customers to prevent them from easily switching away.

klabb33• 2 years ago

Right you could go against the rest of the world and continue with privatized care. I’m sure it could work much better if free markets were enforced, but it’s very much the opposite. US markets are extremely entrenched, especially in highly regulated sectors. Markets are cornered by PE, by acquisitions, by frivolous lawsuits, any means possible to get dominance. And there’s no functioning anti-trust law, so you get the opposite of free markets. Even Milton Friedman claimed that governments have a necessary obligation to interfere to preserve free markets.

BirAdam2• 2 years ago

“Interfere to preserve free markets” is odd. The entire issue in the USA is regulatory capture and bribery of the government. The government has such tremendous lucre from taxing and such authoritarian power that every entity that can exploit it will exploit it. The government’s money and power is the one ring. The idea that the government should interfere is the entire problem. Just things like preventing insurance, a financial product, from being sold across the nation or around the world gives insurers undue power. Don’t get me wrong, in this case, breach of contract is a legal issue and the insurance company should be prosecuted, but Milton Friedman was off on this one by a mile. A government that has been purchased by banks, insurance companies, drug companies, and defense companies cannot act in the market fairly and therefore should not act at all.

FredPret2• 2 years ago

This is more than a free market vs state argument.

This type of thing is a characteristic of any large system - there will be gaps. (I’m trying to explain but not defend these gaps).

Unfortunately, some things only work if it’s a large system, like insurance, government, and AT&T.

For instance, in countries with state health care, there are also serious failings like this kind and of other kinds. For example, by keeping prices low, some of these systems restrict supply. This means long waiting times & lower rates of innovation.

Here in Canada, we have government insurance, not health care, and though it’s been good to me, it’s not perfect. Central control is not some silver bullet, and neither is the free market.

ars• 2 years ago

It's easy to blame the insurance companies, but doing so misses the more important detail: There aren't enough providers. No amount of complaining or regulating the insurance companies is going to change this.

Apocryphon7• 2 years ago

They should still be blamed by misrepresenting the lack of supply in their network. But certainly, medical professions probably need reform to alleviate supply, then of course you get into knock-on effects ranging from malpractice suits/tort reform to medical school tuitions.

On the subject of mental health, it almost feels like we need a Manhattan Project of sorts to deal with the mounting crisis.

LorenPechtel5• 2 years ago

Any longstanding shortage is either a resource limit or because the price is too low.

bryan_w• 2 years ago

The leaders at ambetter should be in jail. The world would be better off if they didn't exist.

hedora• 2 years ago

It's common to hit similar road blocks when trying to get a primary care physician around here (and the in-network specialists won't see you without a referral from a primary care physician, rendering your health insurance worthless for non-emergency care).

The US really needs to get rid of the health insurance industry. Single payer would work as would standardized pricing combined with "if the doctor is licensed the insurance company must accept the bill".

Barring that, there should be SLAs regarding for one-shot online searches or one phone call lookup of in-network care providers.

For example, there could be a guarantee that the top three hits of at least 99% of such attempts each contain the phone number of a doctor's office that is accepting new patients and provides relevant care. If the insurance company falls below that bar, then it should have to refund all the premiums they collected that month (since there's no way to know which customers deferred care due to this bullshit), or be hit with some other fine that'd actually be material to their earnings.

paulryanrogers• 2 years ago

Afraid single payer system would just be hollowed out by conservatives (funded by PE), as it has been in the UK. Doubtful the US has the buy in and the discipline to maintain such a system.

Sadly our private insurance market is an oligopoly that can obscure pricing and collude to increase prices. So it's the worst of both worlds.

LorenPechtel5• 2 years ago

We have three UHC systems in America. Medicare, Medicaid and Tricare. All are typically worse than the private system. You want people to support UHC, fix the system first!

What I would like to see is a SLA requirement that you can submit a request for a doctor who does X and is taking new patients. If you go through that list without finding one that can actually take you in a reasonable period they have 24 hours to remedy the matter or they have to cover at in network rates any doctor you select--and that remains in effect so long as you see that doctor (they can't force you to switch doctors.) Say $100/day + costs if they fail.

They don't need more than a very short period because it shouldn't happen very often in the first place.

NeuroCoder2• 2 years ago

Working in a psych unit trying to improve this process is really eye opening. Some key doctors have put in the effort to turn the inpatient floor from weeks of being trapped to identifying these situations where people simply need actual support established. There's even a special 72 hour turn around program recognizing this situation where the system has failed and what we need is rapid stabilization and setting up the proper support for the person to have therapists, medicine, and support groups while still living their lives. It still has flaws, but there are people that care and are working overtime to fix the system. It's just a very slow process.

todfox• 2 years ago

I once had an insurance plan with a grossly inaccurate provider directory. This cost me a bit as the doctor they suggested to me, verbally on the phone, turned out to be out of network. They later told me it was the doctor’s responsibility to remove themselves from the directories and they often fail to do that. If they’re so incapable of maintaining an accurate list of providers on their own, how did the insurance company know to reject that claim so quickly? They are simply liars and fraudsters.

I began calling random doctors in the directory and one even told me he tried to get his name removed for three years. Anybody at the insurance company could clean up the directory once a quarter. They know the directories are inaccurate. It makes their network look bigger.

Health insurance middlemen need to be eliminated already.

prepend2• 2 years ago

It seems like insurance companies don’t care about things that burden the customer or provider. Lots of onerous forms and weird processes that are wrongly documented.

I had infuriating situations where their directory showed a provider, their phone service confirmed they were in network, but the claim was rejected as out of network. They said they made a mistake and the only way to know is to try to submit a claim. I asked the same thing “if you know to review a claim why don’t your reps or your web site know?”

Reason077• 2 years ago

It sounds like something that would be very easy to fix if the government mandated that insurance companies have a responsibility to keep their provider directories up-to-date. Software should be able to very easily identify providers that have not accepted any claims in a given time period, so that they can be flagged for removal.

mindslight3• 2 years ago

What I don't get is why people seem to just take it? Just because someone sends you a bill does not mean there is a valid debt you actually owe. This goes double in the medical extraction industry where the default behavior is sending bills with large fake amounts "due" and hoping victims don't examine them too closely.

I'm dealing with a similar thing right now where the "insurance" company says something is covered and they will "adjust" it any day now, while the "provider's" billing agent continues sending us fraudulent bills with fraudulent charges. The services were actually provided in a hospital and the hospital's bill was already paid, making these charges baseless for two separate reasons. It's like if you bought food at a supermarket and then a few months later the cashier themselves sent you a bill for several hundred dollars.

So every few months I call them up, tell them that there are fraudulent charges on their statements, and if they send me a payoff statement or corrected bill I am willing and able to pay it in full. They respond that they cannot do that, but emphasize it's really important for me to pay the other charges by their fabricated "due date". I reiterate that I'm not going to pay part of their bill only to have the matter not resolved when they keep sending me fraudulent statements, and that presenting a correct statement is their responsibility. There are certainly better uses of my time, but at this point this medical shakedown cartel is so out of control it's all of our responsibility to hold the line.

underlipton2• 2 years ago

The political cowardice of the Obama administration and congressional Democrats to not just deep-six the private health insurance industry as we knew it when they had the chance, Republican (and Blue Dog) whining be damned, cannot be overstated. It's been 15 years. Think how different our country could be today, how much better off people could have been, if we'd established an American NHS with even half of the money we spend.

It's a little crazy how quick we are to fire individuals who have a negative effect on a given organization, while being so loathe to "fire" the organizations who have a negative effect on our society.

Projectiboga2• 2 years ago

Yep campaign finance laws really feed this mess. Both parties love to blame the Senate Filibuster, but no one want's to eliminate it. This specific problem would end rapidly if the insurance companies were on the hook for having to honor their 'in network' lists, they should be liable for any inaccuracies on that list, and any fighting about money should be between the providers and the insurance companies, both have money to litigate. Patients do not have the time or money to fight effectively.

LorenPechtel5• 2 years ago

Yup, I've seen it also.

None of the snail mail garbage, but I couldn't pry anything out of the portal. The first attempt with the insurance company produced an e-mail that was utterly useless. The second attempt, when I spelled out the problem with the first, produced a completely different list when it should have been a subset except with a greater distance. Of that list I could reject some based on their websites, some were utterly wrong based on calling the office (and in one case a "never heard of them") one had been in an accident and wasn't currently accepting new patients and that left one. And it was the closest one I had looked at, the distance bit was most certainly not relevant.

They need to put a much shorter timeline on the insurance coming up with a suitable practitioner. Say, maybe a day rather than 60 days. And maybe a month to actually get an appointment. And, for an existing situation the clock is set by any important scripts the patient might have. (My hunt was triggered by my getting dumped by the system--I had been grandfathered in when the practice changed. Then the doctor left and the grandfathering ended.)

Projectiboga2• 2 years ago

Simple solution is if the insurance directory says a provider is "in network" than they should be on the hook to honor that and pay the provider and collect the in network deductible from the patient directly. I'd bet that issue would be fixed in a very short time. It is basically fraud for them to have inflated list of supposedly active providers.

musicale• 2 years ago

They are simply liars and fraudsters.

Systematic fraud is very profitable.

copx2• 2 years ago

Man, American healthcare sucks.

Who came up with this "network" idea? I hope they are burning in hell.

Here in Germany I can just go to any doctor/care provider. The insurance companies don't have networks I need to worry about. I have always considered that normal, and think the American system is horrible and perverse.

pas• 2 years ago

How do you know if someone is a care provider or they just say so? ... and that's the problem with the patchwork of states, certification boards, semi-regulated honor systems interconnected with a fuckton of money.

And instead of sufficiently driving out scams[1] from the whole country (or at least from states) there are these mythical "allowlists".

[1] but then muh freedom! and MLMs and religious crazies and spiritual-woo-whatever crazies masquerading as religious crazies, and ...

copx2• 2 years ago

How do you know if someone is a care provider or they just say so?

We have central authorities for that and as a patient I don't have to worry about it.

In the case of public insurance (which over 80% of Germans use) the care provider bills the insurance company, not you. And people can't just pretend to be medical professionals because the insurance company can easily check if you actually have a valid license to practice medicine in Germany. Again there are central authorities for that which maintain registries.

zajio1am• 2 years ago

Really? Here in Czechia, we have similar public healthcare system based on public health insurance providers, and there is still a concept of non-contract doctor/care provider. It is unusual, as most care providers have contracts with most insurance providers, but it exists.

MrDrMcCoy• 2 years ago

You Germans really have it figured out. Social market economy is a great and well proven system. It's a pity that my fellow Americans conflate it with socialism, which is one of the few things that would be worse than what we have now.

more_corn• 2 years ago

Weaponized incompetence

taurath2• 2 years ago

Ghost mental health networks are a thing. If you need a specialist therapist you will probably not even be able to get a single available provider who takes insurance. The best you can do, if you don't have a bunch of cash on hand or an HSA is get on a waiting list for literal years.

People on medicaid, those who would proportionally probably need more mental healthcare, have the least amount of access (very very few therapists can financially afford to take medicaid), and the worst care (those that do are almost always new grads trying to finish the requirements of an independent license). It is one of the ways that our society deeply punishes the poor.

Many many people especially here will never have experienced this - but some who've say lost a job due to a mental health reason quickly find that as their job goes away so does their ability to access care. Then they have to decide between at minimum $400 a month (more likely $700) for food/rent or for therapy.

There is frequently nobody there to help you at the bottom. It can't happen to you until it does.

LeroyRaz• 2 years ago

This isn't normal. No other developed country has these issues.

How can any American be proud of their country?

mu533• 2 years ago

what country are you from?

howard941• 2 years ago

Know what else sucks? A provider in your network at the beginning of the year and then dropping out partway through the year. Now I'm stuck for the rest of the year with insurance that I can't change that doesn't cover the provider it was chosen for. Recourse?

hackable_sand• 2 years ago

This is chilling. It lines up with my experience except I made it out with scars.

People still judge me for them so I wear them openly and talk about them openly.

xtracto5• 2 years ago

This reads so fucked up... pardon my language . But after every paragraph I was shouting "why don't you go to a private psychiatrist, even if it is out of the insurers network!!!!"

Of course I already know the amswer: apparently in the US the cost of that is prohibite. Over here I can go to doctoralia.com.mx and book a next day specialist for at most $100 for the first consultation. Just to get my message, and the ask him to help him refer to whoever takes my insurance, if needed.

US health system keeps beeing THE reason why I would never think to migrate to that country. No matter how pretty the American Dream sounds like.

chriscappuccio• 2 years ago

Maybe at the point when this guy figured out that drinking a fifth a day was bad, and his insurance company was a piece of shit, he could have thought, I'll do something else. Jujitsu ? AA ? Heck, go to a church. Try one of those cheap ketamine clinics if you have to...come on, there are so many ways... I get it, you have insurance and it would be nice to use it but many, many medical interventions are flawed and the services are not going to fix your life for you. As this poor guy unfortunately discovered when he thought that his plan was going to help. No, it probably won't, and even a good provider may not be of much help.

0xcde4c3db3• 2 years ago

I think it's worth seriously considering the possibility that that he felt like he was at the end of his rope partly because he did try a bunch of other things and none of them substantially helped. Especially considering that he moved out of downtown Austin, where there was presumably no shortage of options. The article mentions that he hadn't found a "new" AA group in Phoenix, which wouldn't make sense unless he had one previously.

tareqak• 2 years ago

I’ve had a similar experience with an insurance provider with similarly outdated providers when I was in Arizona.

One of the care providers that was listed was one that I had previously seen in California (the education/ alma mater, name, etc. were all the same). I did end up calling to make sure, and found that my hunch at the time of this information being horribly stale was correct.

hut8• 2 years ago

https://www.timesunion.com/health/article/attorney-general-s...

We have a huge problem with this in New York.

39896880• 2 years ago

What is most horrifying about this story is it is not about a person who is poor, or stuck in their ways and refusing help. It is about a person with both the will to get better and a caring family member advocating for him. If that kind of person can't get help, what chance does anyone else have?

'I Don't Want to Die.' He needed mental health care. He found a ghost network

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