Vanessa Saba for ProPublica
If you happen to or somebody you recognize 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, thought of hurling his physique in entrance of a shifting bus. He had been feeling more and more alone and depressed; anxious and unlovable; 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 overseas accent. His identify was Giovanni.
“How can I show you how to as we speak?” Giovanni requested.
“Hello, I’m looking for a psychiatric care supplier,” Ravi mentioned.
“So, you might be in search of 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 positively show you how to with that,” Giovanni mentioned. “By the way in which, it’s your first time calling with regard to this concern?”
Ravi paused. It was really the sixth try and get somebody, anybody, at Ambetter to offer him or his mom the identify of a therapist who accepted his insurance coverage plan and will see him. Regardless of repeatedly looking the Ambetter portal and calling customer support, all that they had turned up to date, he instructed Giovanni, have been the names of two psychologists. One not took his insurance coverage. The opposite, inexplicably, examined sufferers for Alzheimer’s illness and dementia and didn’t observe remedy in any respect.
“I’m just a little involved about all this,” Ravi mentioned.
This had not been a part of the plan Ravi had hatched a number of months earlier to save lots of his personal life. Recognized with despair and nervousness, and dwelling within the coronary heart of Austin, Texas’ boisterous Sixth Avenue bar district, the 36-year-old former school golfer had turn into reliant on a harmful type of self-medication.
His heavy ingesting had value 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 have been contributing to his habit and vice versa. She had coached him by way of makes an attempt to get sober.
He needed to save lots of his enterprise, which bought dream holidays to golfers desirous to play the world’s legendary programs. He needed to fall in love once more, also have a child. He couldn’t try this when he was ingesting 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 town the place he’d spent his remaining years of highschool. Phoenix symbolized a happier and more healthy section. They agreed that for the concept to work, he wanted to discover a new therapist there as shortly as potential 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 often known as Blue Cross Blue Protect or UnitedHealthcare. However it was the preferred possibility on HealthCare.gov, the federal medical insurance market, masking greater than 2 million folks throughout the nation. For $379 a month, his plan appeared to have a strong community of suppliers.
Ravi had moved to Arizona, hoping for a recent begin. Right here, he’s along 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 might be deceiving.
After misunderstanding Ravi’s request for a therapist, Giovanni pulled up an inner listing and instructed 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 will not be …” Ravi responded, “I imply … I wouldn’t qualify for that.”
Irritated however well mannered, Ravi requested Giovanni to e-mail the supplier listing on the rep’s pc. He figured that having the listing, which he was legally entitled to, would velocity up the method of discovering assist.
However Giovanni mentioned that he couldn’t e-mail the listing. 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 may take.
Seven to 10 enterprise days to course of, Giovanni responded, along with no matter time it might take for the listing to be delivered. Ravi couldn’t assist however snort on the absurdity.
“Nothing private,” he instructed 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 way of Ambetter’s web site, inspecting the portal of suppliers by way of his thick-rimmed glasses. He known as one after the following, hoping to make an appointment as shortly as potential.
After all, it was unreasonable to count on 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 pals about his difficulties find care:
“Therapists have been 0-4.”
“Referred to as ten locations and nothing.”
“The insurance coverage portal doesn’t know sh—.”
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 tens of millions of People, was trapped in a “ghost community.” As a few of these folks 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 sluggish 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 corporations that leads clients to imagine there are extra choices for care than really exist.
Ambetter’s dad or mum firm, Centene, has been accused quite a few instances of presiding over ghost networks. One of many 25 largest firms 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 completely different names. Along with insuring the most important variety of market clients, it’s the largest participant in Medicaid managed care and a large in Medicare Benefit, insurance coverage for seniors that’s supplied by personal corporations as a substitute of the federal authorities.
ProPublica reached out to Centene and the subsidiary that oversaw Ravi’s plan greater than two dozen instances and despatched them each an in depth listing 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 accordance 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 corporations “deliberately and knowingly misrepresented” the variety of in-network suppliers by publishing inaccurate directories. Centene attorneys wrote in a court docket submitting that the corporate “denies that it made any misrepresentations to shoppers.” The case is ongoing.
And in 2021, San Diego’s metropolis lawyer 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 have been unable to see new sufferers, the criticism mentioned. Town is interesting after a decide sided with Centene on technical grounds.
Even the subsidiary liable for Ravi’s plan had gotten in bother. Regulators with the Arizona Division of Insurance coverage and Monetary Establishments present in 2021 that Well being Internet of Arizona had failed to keep up correct supplier directories. The regulators didn’t advantageous Well being Internet of Arizona, which promised to handle that violation. When ProPublica requested if the corporate had made these fixes, the division mentioned in an announcement that such info was thought-about “confidential.”
These have been precisely the kind of failures that Ravi’s mom, Barbara Webber, confronted as the pinnacle of an advocacy group that lobbied for better well being care entry in New Mexico. From her Albuquerque residence greater than 300 miles away from her son’s his new, Twelfth-floor studio, she listened to Ravi vent about how onerous 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, and so they 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 daily. 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 residence 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 want and skill to assist him, Ravi didn’t wish to keep along with his mother for any longer than vital. He didn’t wish to really feel like a teen once more.
Barbara understood her son’s want for independence, and when he first encountered insurance coverage limitations, she drew from her experience and coached him by way of methods to attempt to get previous them. However by the center of February, a number 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 taking a look at on-line. However Khem Padilla, a customer support rep who gave the impression 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 solely served sufferers with autism. “I want that all the things 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] overlook that you’re Beloved.”
Loneliness is likely one of the strongest forces for triggering a relapse in somebody hooked on alcohol, and Ravi’s early days in Phoenix supplied a harmful dose.
His outdated pals have 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 relationship apps. (“Phoenix Tinder is a wasteland,” he instructed one pal.) 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 instructed his mother.
Alone in his residence with Finn, vodka inside attain, Ravi felt responsible about calling his family members for assist. Regardless that his mother and his pals would decide up the cellphone at nearly any hour, Ravi hated the concept 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 annoyed textual content message to his mother.
“How is it this difficult?!” 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 received him a referral for a psychiatric nurse practitioner, however she wasn’t capable of join him to a therapist.
With out remedy, Ravi’s descent took on a momentum of its personal.
A detailed pal from highschool, David Stanfield, was watching all of it unfold. Ravi had at all times made David really feel like they may decide up the place they’d final left issues. However this new withdrawn individual, who would break right into a sweat on a crisp night time 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 number of years earlier. So when Ravi despatched a sequence of distressing texts, indicating that he had relapsed, David and one other pal staged an intervention and took Ravi to the hospital.
However Ravi questioned what good one other detox would do if it didn’t assist him fight the foundation causes of his habit by way of remedy. He was additionally anxious that it might get in the way in which of his means to work; Ravi was nonetheless reserving some golf holidays by way of his enterprise and figured he must give up his cellphone throughout a rehab keep.
As a substitute, Ravi sated his withdrawals by feeding his physique extra alcohol, giving technique to a March whirlwind of blackouts, huge hangovers and despondent texts to pals. When Ravi confirmed as much as a baseball sport trying pale and raveled, a pal’s younger son turned to his dad and requested: Is Ravi OK?
By early April, nearly two months had handed since Barbara’s first name to Ambetter alerting them that Ravi was having bother discovering a therapist. Ambetter was obligated by state regulation to offer 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 in search of remedy for alcohol withdrawal and known as a disaster line after he had thought of 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.
The care supervisor known as Ravi 4 instances over two weeks, proper as his psychological well being disaster worsened. When he didn’t reply, she closed his case on April 7. The care supervisor 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 count on to spend Mom’s Day with Ravi. However after he instructed 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 Could 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 up to now month and fourth for the reason that yr started. Medical doctors gave him benzodiazepines, Valium and Librium, to deal with the seizures and nervousness attributable to his alcohol withdrawal. “Mother,” Ravi instructed Barbara, “I don’t wish to die.”
One form of remedy urged by hospital employees, an intensive outpatient program, appeared the most effective match. It could enable Ravi entry to his cellphone for his enterprise functions. However neither Ravi nor Barbara might get an inventory of in-network applications from Ambetter, nor might they discover them within the portal.
As Ravi known as each program he might find in metro Phoenix, and did not 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 supplied the names of two in-network applications out of the handfuls in Arizona. Just one supplied the person remedy Ravi was in search of.
That Friday, Could 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. Remedy applications typically prohibit sufferers who take a look at optimistic for these medication due to the legal responsibility, specialists instructed ProPublica. Pinnacle Peak Restoration’s employees urged Ravi to come back again the next week. Barbara flew house, hopeful that Ravi can be admitted. (Pinnacle Peak Restoration didn’t reply to a number of requests for remark.)
On Monday morning, Ravi wrote the date, Could 22, on a sheet of paper. He tore it out of a pocket book, held it as much as the facet 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 medication have been nonetheless in his system. “I don’t know what else to do,” he instructed Barbara over the cellphone. “I’m screwed.”
The reply of what else might be accomplished was, unbeknownst to Ravi, buried within the advantageous print of his personal insurance coverage coverage. Ambetter’s contract promised to search out an out-of-network remedy program and make it obtainable to Ravi, as long as Ambetter’s personal workers determined that it was in his “finest curiosity.”
Regardless that Barbara hadn’t learn the advantageous 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 remedy program, Ravi was certain to relapse. If that occurred, Barbara pleaded, there was an excellent probability that he would have one other seizure. She warned that he may even die.
Barbara awaited phrase on what to do subsequent. She received no response.
The next morning, Could 27, she drafted a message to Ravi. She described her visceral reminiscence of his current seizure.
She wrote that she 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 preserve going — not for her, not for Finn, not for his pals, not for anybody else. “I really like you,” she wrote, “however you will need to love your self.”
She hit ship. Ravi didn’t reply straight away, 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 way of.
Not realizing 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 facet. When nobody answered, the officer known as David, letting him know that the police couldn’t enter the residence 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 ground residence.
When the guard unlocked the door, Finn squeezed previous and darted out. As Aly grabbed Finn, David peered inside, calling out his pal’s identify. 4 empty vodka bottles have been strewn throughout the residence. The Murphy mattress was folded up towards the wall. Nobody gave the impression to be there.
David glanced towards the window that frames the Phoenix skyline and felt a way of reduction. His pal may 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 have 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.
In regards to the Reporting
This story was pieced collectively from greater than 1,000 pages of Ravi’s medical information and insurance coverage recordsdata; audio recordings of Ambetter customer support calls; police experiences and photographs; court docket filings from three states; experiences 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 finest.
It was additionally guided by a prolonged chronology of key occasions that Barbara had compiled within the months after her son’s loss of life. One factor she couldn’t deliver herself to do: learn the post-mortem report. She requested her sister to summarize the findings, which ProPublica obtained and reviewed. Ravi’s loss of life was dominated an accident, possible on account of problems from extreme ingesting.
ProPublica despatched an in depth account of Ravi’s makes an attempt to get assist to 12 authorized, insurance coverage and psychological well being specialists. 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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