Nathan Younger and his dependancy remedy empire have mounted a full-throated protection of how they do enterprise, turning the tables on Aetna — their accuser — by asserting that the insurance coverage big greedily endangers addicts’ lives by reducing remedy brief.
“In addiction treatment, more is generally better,” the counterclaim by Younger and associates filed on Thanksgiving eve mentioned. “Decades of research point to longer treatment as the number one predictor of a successful addiction treatment outcome.
“Aetna, one of America’s largest health insurance companies, disagrees. Aetna believes — contrary to the evidence and to common sense — that less is more when it comes to addiction treatment. Why? Because that way Aetna (and/or the plans it administers) keep more money.”
Within the $40 million lawsuit that kicked off this confrontation, Aetna accused Younger and associates of weaponizing dependancy for revenue. They lured sufferers into their applications by providing kickbacks, resembling free or low-cost residing preparations in “sober living homes” in extremely fascinating places all through California, the go well with asserted. “In reality, the sober living homes were little more than drug dens, used to ensure patients remained in Defendants’ treatment ‘programs’ for as long as possible…. ensuring reliance on treatment rather than recovery from treatment,” the go well with mentioned.
Younger and Co. denied Aetna’s costs of fraud and wrongdoing, mentioned Aetna did not state details enough to represent a reason for motion, has exceeded statutes of limitations, and lacks standing to convey its claims in court docket.
Their counterclaim “seeks redress for Aetna’s fraudulent and unlawful business practices, breaches of express and implied contracts, and failure to comply with state and federal mandates protecting those suffering from (substance use disorder), which wrongful conduct Aetna has unleashed to unjustly enrich itself to the tune of millions of dollars in unpaid claims, causing Counterclaimants yet millions more in damages.”
Attorneys for Aetna didn’t touch upon the countersuit Monday.
Deja vu?
The Southern California Information Group has been documenting the expertise of former workers who mentioned they had been requested to lie or commit fraud, of former sufferers who assert that they obtained poor care, and of regulators who’ve suspended licenses for some Younger-related services, saying they had been “harmful to client health and safety due to significant non-compliance with regulatory standards.”
Younger and associates have denied any wrongdoing. Managers chalked up complaints to disgruntled ex-employees who didn’t carry out as much as expectations and have axes to grind. Attorneys for Younger have contested actions towards the licenses.
In the event you’re having a slight sense of deja vu, it may be as a result of now-defunct Sovereign Well being had an identical suit-and-countersuit tussle with insurer Well being Internet some years again.
Within the back-and-forth over who was really evil — the massive unhealthy insurance coverage firm, refusing to pay for desperately wanted dependancy remedy for weak sufferers or the grasping, manipulative remedy supplier, milking these weak sufferers for each final cent it might wring out of their insurers, then kicking them to the curb when advantages ran out? — Well being Internet received huge, with $45 million in damages and curiosity towards Sovereign.
‘Love and acceptance’
The countersuit paints Younger’s operations in a saintly gentle. In contrast to many different remedy services, Younger’s are prepared to deal with homeless individuals, these with conduct points, prior convictions or different regulation enforcement historical past that “fancier” suppliers would possibly flip away, the countersuit mentioned.
“Providers thus distinguish themselves in the treatment community by their diverse client base and philosophy of love and acceptance, not judgment,” the countersuit mentioned. They supply high-quality, invaluable providers, and Aetna’s actual gripe is that they offered “too much healthcare to too many addicted Aetna enrollees,” the countersuit mentioned.
The insurer “cynically and unscientifically” conflates a number of remedy episodes, that are widespread within the restoration course of, with fraud, the countersuit mentioned. However relapse is a standard actuality and one of many standards used to diagnose substance use dysfunction, it mentioned.
“Aetna’s assumptions are dangerous and wrong,” the countersuit mentioned. “Recovery is a continuous, nonlinear process for most. Recovering addicts often require life-long support to stay sober. Aetna does not want to deal with such complexity and its cost. It would prefer if someone else paid to keep addicted individuals safe and sober. It is that simple.”
Whereas Aetna claimed that Younger’s scheme was to cycle sufferers from one enterprise to a different and encourage relapse so billing cycles might begin anew, Younger claimed that Aetna’s scheme was to indefinitely delay paying claims “by implementing a sham ‘prepayment review’ audit” that allowed Aetna to keep away from paying greater than $16.4 million in claims and sought to put on down Younger’s operation “with endless and repetitive audit processes leading nowhere.”
“Aetna knows that erecting obstacles to addiction treatment will result in less treatment, meaning less cost to Aetna and plan sponsors,” the countersuit mentioned. “But addicted individuals who receive less treatment are more likely to fall deeper into addiction, to give up on recovery altogether, to lose their jobs…. They are at greater risk of becoming houseless and even dying. They are a problem for government healthcare, for first responders, and for local emergency rooms, not Aetna.”
‘Devastated’
Aetna sued Younger and Co. solely after Younger and Co. threatened to sue Aetna for a number of state and federal regulation violations, the countersuit mentioned. Solely then did they study of Aetna’s “body brokering” costs – which had been alleged when the services had completely different house owners and with out proof, it mentioned.
“Aetna’s policies and practices (1) stigmatize and blame the victim and assisting provider, (2) mischaracterize relapse as inherently fraudulent, (3) mischaracterize repeated treatments or ‘prolonged’ treatments as inherently fraudulent, (4) mischaracterize courses of treatment in excess of a week or two as inherently fraudulent, and (5) mischaracterize Providers’ lawful actions facilitating access to treatment for addicted individuals as inherently fraudulent or illegal,” the countersuit mentioned.
Aetna’s actions have devastated Younger’s companies and attracted unwarranted scrutiny from different insurers, the countersuit mentioned. And the insurer is not any angel: The state has taken 191 enforcement actions towards Aetna Well being of California since 2001, together with fines for failure to supply protection for medically essential psychological well being remedy, failure to supply clear written clarification of denials, and never contesting claims inside required time frames, the counterclaim mentioned.
“Aetna’s practices likely contribute to increased and prolonged suffering, and even death, of enrollees suffering from addiction,” the countersuit mentioned.
Younger calls for a jury trial and seeks to get well damages, curiosity, attorneys’ charges and bills.
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