(Centene sued for inadequate network coverage)
Centene Health Net has been sued in a class-action lawsuit to offer enough network coverage to its customers. Because of their unwillingness to fund BH/SUD providers, Behavioral Centers across California and Arizona refused Health Net-insured patients.
Health insurance does not guarantee access to care.
Kathleen Steinley and Martin Harold Steinley filed a class-action lawsuit against Health Net on May 4, 2018, alleging –
- Misleading claims in PPO policy.
- An insufficient network of contracted providers on behavioral health and substance use disorder (BH/SUD) services has an insufficient network of contracted providers.
- The management of PPO Policies was grossly botched.
- Inequitable distribution of benefits for BH/SUD services compared to medical and surgical services is due to its irrational investigation of claims and resultant rejection of out-of-network options.
Martin filled out a Health Net Small Business Application for Group Enrollment and selected the Health Net Gold 80 PPO coverage, which will begin on December 1, 2015. He mentioned his family members in the policy registration application, including his wife, Kathleen, their son, Alex, and their other two children.
When he chose the Health Net PPO Policy, he relied on Health Net’s statements about access to a good healthcare provider network. In May 2016, Alex was admitted to Aurora Vista del Mar Hospital in Ventura County, where he notified Kathleen and Martin that they would need to find a BH/SUD residential treatment center where he could be discharged after his stay.
Kathleen began a frantic search for residential treatment clinics that were part of Health Net’s provider network, as represented in advertisements, marketing materials, and a directory accessible through the Health Net website portal.
Health centers refusing to accommodate Health Net-insured patients
Seeking assistance from David Archambault, Kathleen’s insurance broker, she was able to explore the online Health Net Provider Directory with the help of Mr. Archambault. However, she rapidly discovered that there were no in-network providers that could treat Alex, and was dismayed to find out that out-of-network clinicians could not treat a Health Net insured because Health Net had launched a dragnet SIU investigation to stop BH/SUD out-of-network providers from receiving reimbursement.
On May 6, 2016, she was then informed by in-network providers that they either didn’t provide the treatments Alex required, didn’t have any beds available for Alex, or wouldn’t treat him because he was already admitted to a facility with an equivalent level of care.
Out-of-network providers told the Steinleys that although they had vacant space and services provided that Alex needed, they could no longer admit and treat Health Net-insured patients because Health Net declined to compensate BH/SUB out-of-network providers for services that they gave. Kathleen had also spent the whole day researching and contacting treatment facilities that rejected her because her insurance was through Health Net.
On May 7, 2016, Martin contacted Health Net and demanded that they issue a list of in-network providers, which Kathleen had contacted immediately. The providers were rehabilitation hospitals to treat strokes, traumatic brain injury, and other physical rehabilitation services. Not one provider on the list from Health Net was BH/SUD providers. Kathleen was able to get in touch with an organization that helps patients be placed in residential treatment centers across the country but was advised that most out-of-network BH/SUD providers across the government no longer accept Health Net patients.
Kathleen was unable to find a suitable facility willing to treat Alex. Most providers announced that no out-of-network provider in the country would treat Health Net-insured patients. Only two organizations that she worked with could find two suitable residential facilities willing to admit Alex – because of the Health Net’s SIU investigation and closure of reimbursement payments.
Claims against Centene Health Net
- Consumers were deceived by numerous BH/SUD providers’ false names in the Health Net network of contracted providers or in-network providers.
- Misleading representations in advertising, marketing, and communications regarding BH/SD provider networks.
- Delays and interruptions in accessing needed health care in the network of BH/SUD providers.
- Long waiting time on customer service telephone lines would take several hours and even days and weeks in some cases.
- Health Net tricked customers with limited and unsubstantial options of out-of-network BH/SUD providers.
- Insured patients are subject to high healthcare costs due to Health Net’s compensating BH/Sud services which resulted in an underpayment of on average of 70-80% of the providers’ billed charges and an increase in insured patients’ out-of-pocket expenses for covered healthcare services.
Additionally, Health Net underpaid the reimbursement to Steinleys for the expenses incurred at The Canyon, using Medicare compensation rates that do not apply to the services provided. It also underpaid The Canyon’s billed charges and led to an increase in Steinleys’ out-of-pocket expenses for the medically necessary yet covered healthcare services.
Health Net’s conduct was targeted at behavioral health providers and not medical/surgical benefits providers in violation of the Federal Mental Health Parity and Addiction Equity Act. The investigation by Health Net had imposed irreversible loss upon patients and healthcare centers across California and Arizona which were unable to sustain operations.
Treatment providers stated that they cannot afford to accommodate Health Net patients without reimbursement and that the insurer is mistreating its policyholders by limiting their access to treatment.
Centene Health Net is in ongoing litigation with behavioral healthcare centers across California and Arizona for improperly withholding claim payments above $150,000,000.00. In September 2016, Centene’s investor relations chief, Edmund E. Kroll admitted that Health Net had underpaid several drug treatment providers during a health industry conference.
It’s past time for Centene to pay both treatment centers and its insured patients what they’re owed. Their harsh and brutal behavior must stop – it has put its insureds in harm’s way and the livelihoods of several behavioral healthcare institutions and their employees. Centene Health Net has defrauded behavioral health facilities all around Orange County out of legitimate reimbursements.
