California and Oklahoma are separated by greater than 1,000 miles. Inside that span there are tons of — if not hundreds — of habit remedy packages.
“And yet, in the last few years alone, thousands of alleged Oklahoma residents have been trafficked across the country to California under the guise of obtaining (substance use disorder) treatment,” claims a lawsuit filed in federal courtroom Dec. 11 in opposition to two Orange County rehabs, South Coast Behavioral Well being and Rad Life Restoration of Costa Mesa, in addition to others.
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“This surprising migration is not a result of quality treatment. Rather, it is driven by an army of fraudsters that have overrun certain parts of California’s SUD (substance use disorder) treatment industry to prey upon alleged Oklahoma residents, many of whom are members of Native American tribes.”
The one factor these people had in frequent, the go well with mentioned, is that they have been enrolled in Blue Cross Blue Protect of Oklahoma well being plans shortly earlier than their remedy in California started.
“These SUD providers employ a range of fraudulent tactics,” the go well with mentioned. “They hire ‘body brokers’ to hunt down potential patients in exchange for kickbacks. Body brokers work with insurance agents to fraudulently enroll individuals in insurance plans. Once enrolled, patients are shipped across the country to receive ‘treatment,’ the main goal of which is to enrich the providers, body brokers, insurance agents and the others involved in the schemes.
“There are unlawful kickbacks at every level. In fact, many patients themselves receive cash, free ‘treatment’ and housing, which unlawfully influences their choice of providers and induces them to stay under the control of a particular provider so that their insurance can continue to be billed. It is becoming exceedingly difficult for good, quality, providers to operate in an industry awash in kickbacks and de facto bribes.”
Additionally named within the go well with are Excellence Restoration and Every part in Excellence Restoration of Arizona, in addition to three individuals related to the alleged scheme, Cari Passmore, Brett Pershall and Randall Eisworth. Pershall, who had a Santa Ana tackle, mentioned he was within the technique of hiring an legal professional and wouldn’t be commenting. Cellphone messages, emails and texts to the others Monday weren’t instantly returned.
In a modus operandi acquainted to followers of SCNG’s Rehab Riviera protection, Blue Cross Blue Protect of Oklahoma mentioned within the go well with that when insurance coverage advantages are exhausted, suppliers “kick patients to the curb, leaving these vulnerable individuals to fend for themselves thousands of miles from their homes.”
These defendants are among the many worst perpetrators of those ways, the go well with mentioned, and so they’ve obtained greater than $36 million in wrongful funds from Blue Cross Blue Protect of Oklahoma alone. The insurer is suing for fraud, negligent misrepresentation, unjust enrichment, intentional interference with financial/contractual relationships and conspiracy beneath the Racketeer Influenced and Corrupt Organizations Act.
‘Lie’
The go well with alleges that the scheme labored like this:
South Coast Behavioral Well being used physique brokers Passmore and Pershall to entice sufferers west. They tracked down potential shoppers on social media and thru word-of-mouth, with guarantees of free habit remedy.
That remedy was not free, after all, however could be paid for with medical health insurance. Oklahoma insurance coverage agent Eisworth obtained the insurance policies, telling addicts to lie about about their annual earnings, employment standing and residency so that they’d be eligible for Blue Cross Blue Protect plans and authorities subsidies.
One member, recognized as “A,” instructed Eisworth that she held a job that paid far lower than the federal poverty degree. However that made her eligible for Oklahoma’s Medicaid program, public insurance coverage with low reimbursement charges (that wouldn’t cowl remedy outdoors Oklahoma, “much less across the country in California,” based on the lawsuit.
Eisworth instructed her to create a pretend month-to-month earnings assertion exhibiting she was self-employed and that her earnings added as much as greater than $18,000 per 12 months — excessive sufficient to keep away from Medicaid however low sufficient to qualify for personal insurance coverage with far more beneficiant reimbursement charges, in addition to cost-share reductions and a tax subsidy that shrank A’s month-to-month insurance coverage invoice from greater than $500 to lower than $100.
A staggering two-thirds of the tons of of Blue Cross Blue Protect members who obtained remedy at South Coast have been enrolled by Eisworth, the go well with mentioned.
After finishing their “free” in-patient remedy, members went to the sober dwelling facility related to the physique dealer who discovered them, the go well with mentioned. Of us lived in these properties without cost so long as they allowed South Coast to invoice their insurance coverage. South Coast break up these insurance coverage funds with the brokers.
When advantages dried up, members have been typically evicted with little or no discover. After that, based on the go well with, they “suddenly find themselves on the streets with no money to afford housing or the necessities of daily life, much less an expensive trip back home. Putting these already-vulnerable individuals in such desperate circumstances only heightens the chances for relapse.”
This has been occurring way back to 2020 and, to today, “they continue to hunt down individuals to enroll in Oklahoma plans and have taken further actions to infiltrate Oklahoma,” the go well with mentioned.
Along with areas in Costa Mesa, Huntington Seaside, Newport Seaside and Irvine, South Coast Behavioral Well being’s website online lists a location in Oklahoma Metropolis as effectively.
Blue Cross Blue Protect of Oklahoma will not be the one insurer to be victimized by this “racketeering activity,” the go well with mentioned. The well-intentioned Reasonably priced Care Act elevated protection for habit remedy and entry to enrollment, the go well with mentioned, making a panorama ripe for this specific sort of fraud. Oklahoma has the fifth highest charge of habit in America — greater than 16% of its inhabitants, based on the go well with.
“The combination of a state plan offering robust out-of-state benefits and a large population in need of treatment provided a perfect target for profiteers like Defendants,” it mentioned.
Deja vu?
Final month, Blue Cross and Blue Protect of Oklahoma instructed the Southern California Information Group that it’ll cease paying for all habit remedy in California on Jan. 1, with a number of exceptions.
About 1,000 individuals left amenities linked to embattled remedy operator Nathan Younger after this resolution. Former sufferers within the Younger community mentioned they have been signed up for Blue Cross Blue Protect of Oklahoma insurance coverage regardless of by no means dwelling within the state, and typically with out their data.
Younger and associates are being sued by insurer Aetna in a fraud case that echoes this one. Younger has countersued Aetna, saying the insurer is simply attempting to keep away from paying what’s owed.
All of it echoes the battle between Well being Web and now-defunct Sovereign Well being that started in 2016. Well being Web gained large, with $45 million in damages and curiosity in opposition to Sovereign.
On this case, Blue Cross Blue Protect of Oklahoma mentioned in its go well with that it seeks damages “sufficient to punish defendants and deter other persons similarly situated from engaging in similar conduct in the future.”
After so a few years of this situation repeating itself, one would possibly surprise if damages like that basically exist.
