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Comment by trollbridge | Hacker News Reader

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 This is how proper indemnity insurance works, and it would instantly fix the "technical problems" and "out of date directories" that this insurance company in question is suffering from.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.

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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.

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 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.

> 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.

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.

"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.

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

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