Vanessa Saba for ProPublica
In the event you or somebody you realize could also be contemplating suicide or be in disaster, name or textual content 988 to achieve the 988 Suicide & Disaster Lifeline.
Early one morning in February 2023, earlier than the solar rose over Phoenix, Ravi Coutinho went on a stroll and, for a short second, considered hurling his physique in entrance of a transferring bus. He had been feeling more and more alone and depressed; anxious and unlovable; now not certain if he was constructed for this world.
A number of hours later, Ravi swiped open his iPhone and dialed the toll-free quantity on the again of his Ambetter insurance coverage card. After navigating the automated voice system, he was routed to a pleasant, fast-talking customer support rep with a slight international accent. His identify was Giovanni.
“How can I show you how to at the moment?” Giovanni requested.
“Hello, I’m looking for a psychiatric care supplier,” Ravi stated.
“So, you might be searching for a major care supplier?” Giovanni requested.
“No,” Ravi replied, seeming confused. Ravi tried to obviously repeat himself. “Psy-chi-at-ric.”
“Psychiatric, all proper, so, certain, I can undoubtedly show you how to with that,” Giovanni stated. “By the best way, it’s your first time calling with reference to this concern?”
Ravi paused. It was really the sixth try to get somebody, anybody, at Ambetter to provide him or his mom the identify of a therapist who accepted his insurance coverage plan and will see him. Regardless of repeatedly looking out the Ambetter portal and calling customer support, all they’d turned up to date, he informed Giovanni, had been the names of two psychologists. One now not took his insurance coverage. The opposite, inexplicably, examined sufferers for Alzheimer’s illness and dementia and didn’t apply remedy in any respect.
“I’m a bit involved about all this,” Ravi stated.
This had not been a part of the plan Ravi had hatched a couple of months earlier to avoid wasting his personal life. Recognized with despair and nervousness, and residing within the coronary heart of Austin, Texas’ boisterous Sixth Avenue bar district, the 36-year-old former faculty golfer had change into reliant on a harmful type of self-medication.
His heavy consuming had price him his marriage and was on the verge of destroying his liver and his livelihood. His therapist again in Texas had helped him perceive how his psychological diseases had been contributing to his dependancy and vice versa. She had coached him by makes an attempt to get sober.
He needed to avoid wasting his enterprise, which offered dream holidays to golfers desperate to play the world’s legendary programs. He needed to fall in love once more, actually have a child. He couldn’t do this when he was consuming a fifth of a gallon of liquor — the equal of almost 17 pictures — on any given day.
When all else had failed, he and his therapist had mentioned a radical transfer — relocating to the town the place he’d spent his ultimate years of highschool. Phoenix symbolized a happier and more healthy section. They agreed that for the thought to work, he wanted to discover a new therapist there as rapidly as doable and line up care upfront.
Ravi felt relieved when he signed up for an insurance coverage plan proper earlier than the transfer. Ambetter wasn’t as properly generally known as Blue Cross Blue Defend or UnitedHealthcare. Nevertheless it was the most well-liked choice on HealthCare.gov, the federal medical health insurance market, overlaying greater than 2 million individuals throughout the nation. For $379 a month, his plan appeared to have a sturdy community of suppliers.
Ravi had moved to Arizona, hoping for a recent begin. Right here, he’s together with his mom, Barbara Webber.
Webber Coutinho household
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Webber Coutinho household
Irritating cellphone calls like this one started to verify for Ravi what numerous clients — and even Arizona regulators — had already found: Appearances may very well be deceiving.
After misunderstanding Ravi’s request for a therapist, Giovanni pulled up an inner listing and informed Ravi that he had discovered somebody who might assist him.
It was a psychiatrist who specialised in treating the aged. This was unusual, contemplating that Giovanni had requested Ravi to confirm that he was born in 1986. “I imply, geriatric psychiatry isn’t …” Ravi responded, “I imply … I wouldn’t qualify for that.”
Aggravated however well mannered, Ravi requested Giovanni to e-mail the supplier record on the rep’s pc. He figured that having the record, which he was legally entitled to, would velocity up the method of discovering assist.
However Giovanni stated that he couldn’t e-mail the record. The corporate that ran Ambetter must mail it.
“What do you imply, mail?” Ravi requested. “Like bodily mail it?”
Ravi let loose a deep, despondent sigh and requested how lengthy that will take.
Seven to 10 enterprise days to course of, Giovanni responded, along with no matter time it could take for the record to be delivered. Ravi couldn’t assist however snigger on the absurdity.
“Nothing private,” he informed Giovanni. “However that’s not going to work.
“So I’m simply gonna must determine it out.”
***
This baffling incapability to search out assist had tainted Ravi’s recent begin.
Within the weeks earlier than the decision with Giovanni, Ravi had scrolled by Ambetter’s web site, inspecting the portal of suppliers by his thick-rimmed glasses. He known as one after the following, hoping to make an appointment as rapidly as doable.
After all, it was unreasonable to anticipate each therapist in Ambetter’s community to have the ability to settle for him, particularly in a state with an alarming scarcity of them. However he couldn’t even discover a major care physician who might see him inside six weeks and refill his dwindling provide of antidepressants and antianxiety meds.
Days earlier than he was supposed to maneuver to Phoenix, he texted associates about his difficulties find care:
“Therapists have been 0-4.”
“Referred to as ten locations and nothing.”
“The insurance coverage portal doesn’t know shit.”
Ravi Coutinho and his canine, Finn, in March 2023.
Coutinho Webber household
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Coutinho Webber household
Ravi didn’t understand it, however he, like hundreds of thousands of People, was trapped in a “ghost community.” As a few of these individuals have found, the suppliers listed in an insurer’s community have both retired or died. Many different suppliers have stopped accepting insurance coverage — actually because the businesses made it excessively troublesome for them to take action. Some simply aren’t taking new sufferers. Insurers are sometimes gradual to take away them from directories, in the event that they achieve this in any respect. It provides as much as a bait and change by insurance coverage firms that leads clients to imagine there are extra choices for care than really exist.
Ambetter’s mum or dad firm, Centene, has been accused quite a few occasions of presiding over ghost networks. One of many 25 largest companies in America, Centene brings in additional income than Disney, FedEx or PepsiCo, however it’s much less identified as a result of its lots of of subsidiaries use totally different names. Along with insuring the most important variety of market clients, it’s the most important participant in Medicaid managed care and an enormous in Medicare Benefit, insurance coverage for seniors that’s supplied by personal firms as a substitute of the federal authorities.
ProPublica reached out to Centene and the subsidiary that oversaw Ravi’s plan greater than two dozen occasions and despatched them each an in depth record of questions. None of their media representatives responded.
In 2022, Illinois’ insurance coverage director fined one other subsidiary greater than $1 million for psychological health-related violations together with offering clients with an outdated, inaccurate supplier listing. The subsidiary “admitted in writing that they aren’t following Illinois statute” for updating the listing, in line with a report from the state’s Insurance coverage Division.
In a federal lawsuit filed in Illinois that very same yr, Ambetter clients alleged that Centene firms “deliberately and knowingly misrepresented” the variety of in-network suppliers by publishing inaccurate directories. Centene attorneys wrote in a courtroom submitting that the corporate “denies that it made any misrepresentations to customers.” The case is ongoing.
And in 2021, San Diego’s metropolis legal professional sued a number of Centene subsidiaries for “publishing and promoting supplier info they know to be false and deceptive” — over 1 / 4 of these subsidiaries’ in-network psychiatrists had been unable to see new sufferers, the grievance stated. Town is interesting after a choose sided with Centene on technical grounds.
Even the subsidiary liable for Ravi’s plan had gotten in hassle. Regulators with the Arizona Division of Insurance coverage and Monetary Establishments present in 2021 that Well being Web of Arizona had failed to take care of correct supplier directories. The regulators didn’t effective Well being Web of Arizona, which promised to deal with that violation. When ProPublica requested if the corporate had made these fixes, the division stated in an announcement that such info was thought of “confidential.”
These had been precisely the kind of failures that Ravi’s mom, Barbara Webber, confronted as the top of an advocacy group that lobbied for larger well being care entry in New Mexico. From her Albuquerque condominium greater than 300 miles away from her son’s his new, Twelfth-floor studio, she listened to Ravi vent about how exhausting it was to discover a therapist in Phoenix.
Barbara Webber and Ravi Coutinho, in his childhood.
Webber Coutinho household
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Webber Coutinho household
Ravi was Barbara’s solely little one, they usually had at all times been shut. Within the seven years since Ravi’s dad died, they’d grown even nearer. They talked on the cellphone almost each day. Barbara was used to supporting Ravi from afar, ordering him wholesome supply dinners, reminding him to drink sufficient water and urging him to name disaster hotlines amid panic assaults. However when Ravi crashed at her condominium whereas ready to maneuver to Phoenix, she noticed extra of his struggles up shut. At one level, she known as 911 when she feared for his life.
Regardless of her need and talent to assist him, Ravi didn’t wish to keep together with his mother for any longer than essential. He didn’t wish to really feel like a young person once more.
Barbara understood her son’s need for independence, and when he first encountered insurance coverage limitations, she drew from her experience and coached him by methods to attempt to get previous them. However by the center of February, a couple of days after Ravi settled into his new place, there was no excellent news about his psychological well being care. She felt the necessity to step in.
So, she known as Ambetter to attempt to get higher info than what Ravi was on-line. However Khem Padilla, a customer support rep who appeared to be working at a name middle abroad, couldn’t assist her discover that info. She then requested Padilla to ship referrals to therapists.
When Padilla adopted up, he solely despatched cellphone numbers for psychological well being institutes, together with one which completely served sufferers with autism. “I want that all the pieces will work collectively for you,” Padilla wrote in an e-mail to Barbara and Ravi on what occurred to be Valentine’s Day, “and [don’t] neglect that you’re Cherished.”
***
Loneliness is among the strongest forces for triggering a relapse in somebody hooked on alcohol, and Ravi’s early days in Phoenix offered a harmful dose.
His outdated associates had been typically busy with work and household. He hadn’t discovered his technique to a brand new Alcoholics Nameless group but. And he struggled to search out matches on courting apps. (“Phoenix Tinder is a wasteland,” he informed one buddy.) His solely constant companion was Finn, a half-Nice Pyrenees with a thick coat of fluffy white hair, whom he took on lengthy walks across the metropolis. “His unconditional love brings me a lot pleasure,” he’d informed his mother.
Alone in his condominium with Finn, vodka inside attain, Ravi felt responsible about calling his family members for assist. Regardless that his mother and his associates would choose up the cellphone at nearly any hour, Ravi hated the thought of bothering them.
However he couldn’t resist after he hung up with Giovanni, the customer support rep. That afternoon, Feb. 22, he fired off a pissed off textual content message to his mother.
“How is it this tough?!” Ravi seethed.
Barbara’s subsequent transfer was to achieve out to a member of her nonprofit board who occurred to work for a Centene firm. The board member helped get Ravi a care supervisor, an individual who works for the insurer to assist sufferers navigate entry to suppliers. The care supervisor acquired him a referral for a psychiatric nurse practitioner, however she wasn’t in a position to join him to a therapist.
With out remedy, Ravi’s descent took on a momentum of its personal.
An in depth buddy from highschool, David Stanfield, was watching all of it unfold. Ravi had at all times made David really feel like they might choose up the place they’d final left issues. However this new withdrawn individual, who would break right into a sweat on a crisp evening within the 60s, was a far cry from the man he as soon as knew.
Ravi was starting to remind David of his brother-in-law, who had died of a drug overdose a couple of years earlier. So when Ravi despatched a sequence of distressing texts, indicating that he had relapsed, David and one other buddy staged an intervention and took Ravi to the hospital.
However Ravi puzzled what good one other detox would do if it didn’t assist him fight the basis causes of his dependancy by remedy. He was additionally nervous that it could get in the best way of his means to work; Ravi was nonetheless reserving some golf holidays by his enterprise and figured he must give up his cellphone throughout a rehab keep.
As an alternative, Ravi sated his withdrawals by feeding his physique extra alcohol, giving technique to a March whirlwind of blackouts, large hangovers and despondent texts to associates. When Ravi confirmed as much as a baseball sport trying pale and matted, a buddy’s younger son turned to his dad and requested: Is Ravi OK?
By early April, virtually two months had handed since Barbara’s first name to Ambetter alerting them that Ravi was having hassle discovering a therapist. Ambetter was obligated by state legislation to supply one exterior of its community if Ravi couldn’t discover one in a “well timed method” — which, in Arizona, meant inside 60 days.
Vanessa Saba for ProPublica
Inside that span, its personal information confirmed, he’d wound up within the emergency room searching for therapy for alcohol withdrawal and known as a disaster line after he had considered ending his life. But regardless of 21 calls with Ravi and Barbara, including as much as 5 hours and 14 minutes, the insurer’s employees had not lined up a single remedy appointment.
Smith known as Ravi 4 occasions over two weeks, proper as his psychological well being disaster worsened. When he didn’t reply, she closed his case on April 7. Smith didn’t reply to a number of requests for remark or to questions on what info she tried to share with Ravi on these calls.
As Ravi’s makes an attempt to discover a therapist slowed down, his descent accelerated.
***
Barbara didn’t anticipate to spend Mom’s Day with Ravi. However after he informed his uncle that he was having visions once more of leaping in entrance of a dashing bus, she boarded a last-minute flight to Phoenix on Might 12 and settled into his sofa the place she might watch him as he slept.
She was roused by his flailing limbs. He was having a seizure. Paramedics rushed Ravi to the hospital, the second time previously month and fourth because the yr started. Docs gave him benzodiazepines, Valium and Librium, to deal with the seizures and nervousness brought on by his alcohol withdrawal. “Mother,” Ravi informed Barbara, “I don’t wish to die.”
One type of therapy advised by hospital employees, an intensive outpatient program, appeared the very best match. It might enable Ravi entry to his cellphone for his enterprise functions. However neither Ravi nor Barbara might get an inventory of in-network packages from Ambetter, nor might they discover them within the portal.
As Ravi known as each program he might find in metro Phoenix, and didn’t discover a single one which took his insurance coverage, Barbara determined to pester her board member once more. (The board member didn’t reply to a number of requests for remark.)
Barbara Webber and Ravi Coutinho
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A number of days later, somebody with Centene offered the names of two in-network packages out of the handfuls in Arizona. Just one supplied the person remedy Ravi was searching for.
That Friday, Might 19, Barbara rode with Ravi to Scottsdale, the place the consumption employees at Pinnacle Peak Restoration drug-tested him. He examined optimistic for the benzodiazepines the hospital employees had administered following his seizure. Therapy packages generally limit sufferers who take a look at optimistic for these medicine due to the legal responsibility, consultants informed ProPublica. Pinnacle Peak Restoration’s employees urged Ravi to return again the next week. Barbara flew residence, hopeful that Ravi could be admitted. (Pinnacle Peak Restoration didn’t reply to a number of requests for remark.)
On Monday morning, Ravi wrote the date, Might 22, on a sheet of paper. He tore it out of a pocket book, held it as much as the aspect of his face and took a selfie with it. It was a manner of marking time in addition to a milestone: the primary day of his newfound, hopefully everlasting sobriety.
Ravi’s companion, Finn.
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When he returned to Pinnacle Peak, nonetheless, he examined optimistic for benzodiazepines once more. The second rejection damage greater than the primary. Three days later, Ravi went again a 3rd time; the medicine had been nonetheless in his system. “I don’t know what else to do,” he informed Barbara over the cellphone. “I’m screwed.”
The reply of what else may very well be finished was, unbeknownst to Ravi, buried within the effective print of his personal insurance coverage coverage. Ambetter’s contract promised to search out an out-of-network therapy program and make it accessible to Ravi, as long as Ambetter’s personal staff determined that it was in his “greatest curiosity.”
Regardless that Barbara hadn’t learn the effective print both, she had a way that Ambetter might do extra to assist Ravi. So she pulled up the variety of the final Centene worker she’d spoken with.
In a textual content message, Barbara expressed concern that the window to get Ravi assist was closing. She was sure that, with out extra medical assist forward of admission to a therapy program, Ravi was certain to relapse. If that occurred, Barbara pleaded, there was a superb likelihood that he would have one other seizure. She warned that he would possibly even die.
Barbara awaited phrase on what to do subsequent. She acquired no response.
The next morning, Might 27, she drafted a message to Ravi. She described her visceral reminiscence of his latest seizure.
She wrote that he needed nothing greater than for Ravi to be round for the remainder of her years. She promised to assist him it doesn’t matter what. If he stored going, he might discover peace with Finn and discover somebody to like. However he needed to hold going — not for her, not for Finn, not for his associates, not for anybody else. “I like you,” she wrote, “however you need to love your self.”
She hit ship. Ravi didn’t reply immediately, which was uncommon.
An hour handed, then one other. Because the afternoon gave technique to night, Barbara known as 3 times, unable to achieve him. She tried to achieve Phoenix’s 911 dispatch however couldn’t get by.
Not figuring out what else to do, Barbara known as David Stanfield, whom Ravi had requested to be his native emergency contact.
He agreed to name 911.
A police officer knocked on Ravi’s door and will hear Finn barking from the opposite aspect. When nobody answered, the officer known as David, letting him know that the police couldn’t enter the condominium with out the constructing’s safety guard, who wasn’t round proper then.
David and his fiancée, Aly Knauer, drove over to Ravi’s. A safety guard, who had simply gotten again from his rounds, allow them to into the Twelfth flooring condominium.
When the guard unlocked the door, Finn squeezed previous and darted out. As Aly grabbed Finn, David peered inside, calling out his buddy’s identify. 4 empty vodka bottles had been strewn throughout the condominium. The Murphy mattress was folded up in opposition to the wall. Nobody appeared to be there.
David glanced towards the window that frames the Phoenix skyline and felt a way of aid. His buddy would possibly nonetheless be alive.
When he turned to go away, he seemed once more on the Murphy mattress and noticed it was barely ajar. As he leaned nearer, he realized his worst fears had been confirmed. Ravi was trapped between the wall and the mattress, lifeless.
Ravi Coutinho was 36 years outdated. He’d been discharged from the hospital two weeks earlier than.
Concerning the Reporting
This story was pieced collectively from greater than 1,000 pages of Ravi’s medical information and insurance coverage information; audio recordings of Ambetter customer support calls; police reviews and images; courtroom filings from three states; reviews from insurance coverage regulators; Ravi’s texts, cellphone logs, social media messages and emails; and greater than 25 hours of interviews with individuals who knew Ravi greatest.
It was additionally guided by a prolonged chronology of key occasions that Barbara had compiled within the months after her son’s dying. One factor she couldn’t carry herself to do: learn the post-mortem report. She requested her sister to summarize the findings, which ProPublica obtained and reviewed. Ravi’s dying was dominated an accident, seemingly as a consequence of issues from extreme consuming.
ProPublica despatched an in depth account of Ravi’s makes an attempt to get assist to 12 authorized, insurance coverage and psychological well being consultants. They independently recognized a wide range of issues, together with Ambetter’s supplier listing inaccuracies, its community inadequacy and its customer support shortcomings.
***
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