How a Customer Got Trapped in Ambetter's Ghost Network | Hacker News Reader

How a Customer Got Trapped in Ambetter's Ghost Network

propublica.org

89 pointshoward94141 comments

The "problem" can be fixed relatively easily: when an "insurer" fails to cover a loss of one of its insureds using its own providers or network, the insured can simply go to anyone they can find and they or the third-party provider can submit the claim. This is how proper indemnity insurance works, and it would instantly fix the "technical problems" and "out of date directories" that this insurance company in question is suffering from.

In any case, this company is now the target of multiple class-action lawsuits, including one under RICO. It would be interesting to find out in discovery if publishing bogus provider directories was intentional on the company's behalf. If it is, this opens a great deal of liability for them. We are fortunate that 11 states outright ban mandatory arbitration by insurers with another 3 where the courts de-facto ban it. This means insurers can't get away with this forever.

While I have no love for Ambetter, I think we need to ask whether behavioral health services should ever be covered by insurance. From 10,000 feet, the behavioral health product is terrible. There's no clear timeline for how long it takes to get better, and it's nearly impossible to objectively compare provider quality using any publicly available data set. In short, it's a terrible match for insurance as a product. Which is why we're in this pickle.

I would think the highly variable costs make it a great fit. The whole point of insurance is to spread outlier risk across a large group of people.

(To be clear, I have no love for the health insurance industry in general, but it's for reasons other than this.)

Yes. the answer is yes we want mental health to be covered.

i take it you don’t have a lot of experience with the healthcare system prior to 2008 or so when parity for mental health benefits became a requirement. let me tell you what a hellscape it was. it was pretty well accepted practice to never use insurance for mental health, because if you tried, not only would your claim be denied but it would be a preexisting condition forever after that. if you had your GP prescribed an antidepressant —preexisting condition. if you did manage to find someone who took your insurance it was a six month wait for an appointment. and then (because it was pre obamacare) you were highly likely not to be able to get coverage again if you ever had to change insurance providers on the private market. people stayed at jobs years longer than they wanted to solely because of healthcare benefits like mental health.

basically, only those who could afford to pay out of pocket got access to mental health benefits.

i often hear people think out loud, we’re should just let the market dictate X, and it boils my blood because they clearly weren’t paying attention the LAST time we just let the market decide something like this, and it killed a lot of people.

Insurance generally does cover chronic conditions where the patient only stays “better” as long as treatment continues.

> nearly impossible to objectively compare provider quality using any publicly available data set.

That's true for all medical specialties I know of in the US, except there are some useful published measures for hospitals and surgical centers.

> the behavioral health product is terrible

So it is, so are most specialties. But plenty of patients do get actually useful help with basolutely recognizable improvement. Often night and day.

So. Is it useful and needed? Yes.

"We"? Who are "we" here? Isn't this decision completely in the hands of the insurers themselves?

Not really (ultimately, though, the nuclear answer is 'yes'). Many states, including mine, have mandated that for a health insurance carrier to do business/be licensed in our state, that certain minimums for mental healthcare must be met.

It sounds like this is already the case, somewhat. The article says:

> Ambetter was obligated by state law to provide one outside of its network if Ravi couldn’t find one in a “timely manner” — which, in Arizona, meant within 60 days.

(They didn't)

> when an "insurer" fails to cover a loss of one of its insureds using its own providers or network, the insured can simply go to anyone they can find

A variation of this is in effect, though you have to know, and you have to push. If you as a consumer are given reason to believe by the insurer that the provider is in-network, then they are required to cover that provider as if they were in-network, even if not.

Specifically, if the carrier's "Provider Directory" lists that provider...

Challenges - this may not stop the initial out of network billing from the provider that you may have to pay and be reimbursed for, the tier 1 support representatives will stare blankly at you and have no idea what you're talking about, and when and if you get it escalated you'll have to fight for it.

(Also, admittedly, it's only really good for one 'encounter'. After that, the insurer will say that now you have a confirmed belief that they're out of network, so...)

The whole system is so broken.

I had Ambetter for dental insurance when I damaged a tooth and experienced this first hand. I think spent between 30 and 40 hours over two weeks calling Ambetter and dozens dentists all over my state. The worst part, besides not being able to see a dentist, was that to Ambetter, you are always calling for the first time. The system has no memory of your issue or even that you have called five times already that morning. The rep always asks a long list of pointless questions like who your primary care doctor is and if you are still living at your address. (No, I have not moved since I last called 20 minutes ago.) You repeat the same numbers and answers over and over. Then you have to describe your problem again, and plead for help. Even after communicating how many times you have tried, the reps only have one solution and that is to give you three more dentists to call. One time I asked the rep to stay on the phone while I called the numbers so that I wouldn't have to call back after they didn't work. That made him very angry and he hung up on me. The numbers didn't work.

I did finally get to see a dentist though. Near the end of the second week, one rep's voice seemed more empathetic and hearing her listen made me chock up as I described how difficult the process had been. She gave me a line to say to the other reps to have them transfer my call to her and told me to call back the next morning. I don't know what she did, maybe there was even something broken with my account, but she found me a dentist within walking distance of my house.

The concept of "in network" is so foreign to me as someone from a developed country that isn't America. We don't have public coverage for mental health services unless you're below the poverty line, but you can pick any therapist and send the receipt to your insurance company to get coverage (up to a limit).

If you’re curious about how this system came about, this article has a great historical overview: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193322/

Is there a TL;DR?

article alleges Ambetter failed to provide care to a patient despite best efforts of patient and family, laws and decency. The purpose of the system is what it does. CEO seems to be paid $18M/yr. And so it goes.

Government health care subsidies and purchasing programs have completely destroyed the market for services. It's an incomprehensible mess of products with a bloated middle layer that only exists to extract value out of the actual Consumer + Expert Care Provider equation to the extreme detriment of both of them.

How anyone stays alive and wealthy in such a system is beyond me. Very few, apparently, are fortunate enough to enjoy this. We need to completely rethink this entire model.

It’s almost as if people warned about this very thing. It’s almost as of anything the government touches turns to crap for most while a few, especially those in Congress, ride off with a huge pay day. I’m not sure why people continue to fall for it.

We just need to create more agencies, throw more money at the existing programs, establish new programs, and add more regulations. This time for sure

Probably a few commissions as well. And adjust for inflation.

I assume this is a criticism of the ACA. How, specifically, did it lead to this outcome?

And why is your criticism reserved for the government and not the perpetrator of the fraud, namely Ambetter?

yes, things tend to turn to crap when you have half the government composed of a party dedicated to ensuring that everything government touches turns to crap or benefits the wealthy. not sure how this is a valid point or makes the case that allowing industry to police itself will work.

When that’s the game, don’t let them play. The party you’re referring to is ambiguous. Democrats seem to make an awful lot representing their constituents[0].

Health insurance shouldn’t exist. When the government mandates it, now there are two problems. If this wasn’t obvious prior to the ACA, I have a bridge to sell you.

0 - https://ballotpedia.org/Changes_in_Net_Worth_of_U.S._Senator...

Christ, reading Americans declare that the issue with American healthcare is "too much government" always completely floors me. The system did not work well before the ACA, the system does not work now. The only countries in the world with strong, consistent and equitable healthcare systems have government health systems.

Here in the UK our NHS is a goddamn mess, it's cracking and creaking and bureaucratic, but every American expat i have ever known who now lives in the UK has horror stories about how much worse it is over there. In our monthly social classes (PSHCE) we watched documentaries of poor Americans unable to afford healthcare, and it horrified us all.

You can't run healthcare as a profit seeking enterprise, it just doesn't work, the financial incentives of healthcare providers just fundamentally do not align with their customers. Government run institutions can often fall into a state of bureaucratic atrophy but if this and countless other stories make clear - that's an issue with institutions in general, whether they be government run or not.

This problem will not improve until you get over your ideological commitment to trying to solve every problem with markets. Healthcare must be socialised, anything less is barbarism.

Health insurance is the problem and always has been the problem. Having the government mandate insurance is far worse than a public health system. Currently we have the worst of all of the options (and if an insurance company has bought all of the smaller providers in your area, it’s even worse)!

Healthcare hasn’t been a “market” in decades. It’s completely captured by monopolies which have captured regulation to prevent any alternatives. I do know that the mashup of government mandates for for-profit entities is about as corrupt a system as could be conceived.

> The system did not work well before the ACA

It wasn't nearly as corrupt.

> we watched documentaries of poor Americans unable to afford healthcare, and it horrified us all.

A system so good shouldn't need such propaganda to justify it's existence.

> you get over your ideological commitment

The ideological commitment that are the underpinnings of our system of government and the core of our very constitution? Why don't you just "get over" your ideological commitment to entertaining that absurd royal family?

By what metric are you evaluating corruption here, other than selected news anecdotes that support your ideological intuition.

We watched videos of the horrors of the American healthcare system for the same reason as we watched videos and were otherwise taught about oppressive regimes, international poverty, bigotry and racism both local and international - to learn about global issues, to gain a wider perspective on the world, to be knowledgeable about the many ways in which a society can fail it's most vulnerable. Such as, for instance, letting your poor die and suffer from preventable, curable illnesses.

Oh, and I have no such ideological commitment to the monarchy, I and most people I know would choose to abolish it in a heartbeat. It is here, as it is everywhere, the conservative right clinging onto traditions, ideologies and policies that have long since proven unproductive, disfunctional or outright harmful.

The monarchy may well underpin much of how British law and government works, and that is something we should work to change - just as you in the US should work to change those parts of your founding constitution written almost 300 years ago that no are no longer to the benefit of yourselves and your country.

If I didn’t have healthcare on the Obamacare market today, my special needs son would be without care because I can’t afford his care myself. Furthermore, his healthcare would have been impossible to even get privately because of all that preexisting conditions BS. People like you probably don’t care about anyone else, but ACA is a life saver for so many people.

You pay for insurance, which pays for Dr’s insurance, which pays other people absurd amounts for malpractice. If you weren’t having to pay two insurance companies with awfully large buildings, naming rights to stadiums, etc., maybe you could pay for that without government assistance. Somehow people did it successfully for millennia.

> Somehow people did it successfully for millennia.

No, they didn't. People with unusual medical needs just died. Heck, people with what we now view as pretty routine medical needs just died.

> which pays other people absurd amounts for malpractice

Many states now cap malpractice insurance. Also, malpractice insurance is not as crippling to physicians as some would have you believe.

OMG it was truly paradise before the ACA.

That is sarcasm if you can't tell.

As someone that used the open market plans before the ACA, it basically changed nothing, added subsidies, and removed the lifetime limits, at least from my perspective.

But this is all pointless accounting bullshit, we simply need a medicare-for-all plan.

I was on employee plans until recently. I knew I would eventually need private health insurance and watched it for 5-10 years, during which ACA took over. For most, premiums rose and coverage fell. Maybe that would have happened regardless, but that wasn’t the ACA promise. Prior to ACA, growth of per capita health care costs were slowing.[0]

0 - https://www.healthsystemtracker.org/chart-collection/u-s-spe...

The ACA was a disappointment, don't get me wrong. It should have been medicare for all but...

Fucking Joe Lieberman.

Granted, whenever democrats are in power, they rotate the "bad guy" to give in to the corporate demands and side with the Republicans, but Joe Lieberman was the reason we got a washed out reformed healthcare. Sure it could have been some other democrat senator turncoat, but he wasn't being the surreptitious underminer while the Republicans did the public PR, that a-hole was front and center hollowing out the ACA.

Joe Lieberman probably killed hundreds of thousands of Americans as a result. Maybe a million. Maybe more.

Hold up, how does this type of fraud require any government action at all? (Except for prosecuting the fraud after-the-fact, of course.)

The core situation isn't specific to healthcare either: Someone's offering you a long-term contract service based on the strength of a menu of available services and options, but their offering is effectively fake.

It's a similar concept to subscribing to a mostly-fake library of repair manuals or something, only the popular/cheap ones are there, and the others are permanently temporarily unavailable.

> Hold up, how this type of fraud require any government involvement at all?

Hold up (seriously hold up and stop serially editing your comments), where did I say it did?

> It's a similar concept

The government has decided, without much input from actual citizens, that copyright should exist for life plus 70 years. Government interference in copyright has created the fraudulent market conditions you've just related.

We can do this all day if you like.

I can still give you a fake repair manual subscription with or without copyright.

To move this false-advertising example even further from copyright, imagine a subscription-based Ice Cream of The Month club, where 24 months of continuous membership entitles you to The Super Expensive Awesome Flavor that never actually existed.

Technically.. sure.. you can also sell buggy whips. If there's no market for what you are selling then why would anyone buy it?

Why are you putting the word "government" in there? The main perpetrator of this particular problem is the health "insurance" cartel with their closed "networks". This regime was directly created and nurtured by government-based regulatory capture, but that does not mean that removing government from the equation will cause the "insurers" to spontaneously dismantle their lucrative positions.

So directing the ire at "government" seems like it's directly detracting from focusing on the problem, which is a complete lack of sensible regulation of these "private" corporate extraction machines. At a minimum this "network" nonsense needs to be outright banned for the restraint of trade scheme that it is, and "providers" need to be taken to task for shaking down patients with fraudulent bills not based on any sort of contract (the latter being the main thing driving people into the arms of these "insurers" to begin with).

> Government health care subsidies and purchasing programs have completely destroyed the market for services.

No it hasn't. People will happily take cash. Some of the offices called in this article suggested they only took patients who pay cash.

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