A Centene subsidiary is now facing a lawsuit filed by the mother of a deceased member in Arizona for allegedly failing to provide adequate access to mental health coverage.
The lawsuit centers around the death of Ravy Coutinho, who died allegedly because Centene subsidiary Health Net of Arizona failed to adhere to law requiring appropriate access to mental healthcare.
This, the lawsuit claims, is a result of ghost networks – inaccurate and misleading provider directories that falsely list providers as in-network and available when they're not.
Health plans and insurers are responsible for maintaining and updating provider directories.
WHAT'S THE IMPACT
According to the filing, Coutinho moved to Arizona in 2023 and sought a therapist, signing up for a plan with Centene company Ambetter Health through the Affordable Care Act exchange. Records of phone calls Coutinho placed to Ambetter show the company failed to email him a list of relevant and eligible providers despite more than 20 documented phone calls. Coutinho was unable to find a primary care doctor to refill his antidepressant prescription even after manually sifting through the directory's list of providers.
The lawsuit accuses Centene and its subsidiaries of intentionally inflating their provider directories to attract customers. It claims Health Net and Ambetter lacked sufficient in-network providers for mental health and substance abuse treatment, and that the provider directory was not updated as required by the ACA, Parity Act and No Surprises Act.
Coutinho allegedly dealt with these issues for about five months, at which point he suffered from hallucinations and suicidal ideation. He died in May 2023.
The suit accuses Centene of wrongful death, as well as negligence and negligent misrepresentation for allegedly falsely representing its provider network and failing to disclose material facts. It also accuses Centene of consumer fraud and insurance fraud, for allegedly misrepresenting coverage benefits, directory accuracy and plan adequacy – a felony under Arizona law.
The suit seeks wrongful death and punitive damages.
THE LARGER TREND
Anthem Blue Cross Blue Shield of New York was accused of maintaining a ghost network in a lawsuit filed in the Southern District of New York in late 2024.
Patients allegedly experienced care delays due to inaccurate provider directories, and some pursued pricey out-of-network care. Many were surprised that most of the doctors in the network didn't accept their insurance plan.
The law firms representing the plaintiffs said ghost networks cause significant financial harm to patients because going out of network for their care incurs substantial expenses, as well as delays in finding essential care. Often, patients abandon seeking care because they can't find in-network doctors who accept their insurance.
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.