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Nathan Younger and his dependancy therapy 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 therapy brief.
“In dependancy therapy, extra is mostly higher,” the counterclaim by Young and associates filed on Thanksgiving eve stated. “Many years of analysis level to longer therapy because the primary predictor of a profitable dependancy therapy final result.
“Aetna, considered one of America’s largest medical health insurance firms, disagrees. Aetna believes — opposite to the proof and to frequent sense — that much less is extra in relation to dependancy therapy. Why? As a result of that means Aetna (and/or the plans it administers) preserve extra 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 packages by providing kickbacks, resembling free or low-cost dwelling preparations in “sober dwelling properties” in extremely fascinating places all through California, the swimsuit asserted. “In actuality, the sober dwelling properties have been little greater than drug dens, used to make sure sufferers remained in Defendants’ therapy ‘packages’ for so long as attainable…. making certain reliance on therapy slightly than restoration from therapy,” the swimsuit stated.
Younger and Co. denied Aetna’s fees of fraud and wrongdoing, stated Aetna did not state information enough to represent a reason behind motion, has exceeded statutes of limitations, and lacks standing to deliver its claims in court docket.
Their counterclaim “seeks redress for Aetna’s fraudulent and illegal enterprise practices, breaches of specific and implied contracts, and failure to adjust to state and federal mandates defending these affected by (substance use dysfunction), which wrongful conduct Aetna has unleashed to unjustly enrich itself to the tune of thousands and thousands of {dollars} in unpaid claims, inflicting Counterclaimants but thousands and thousands extra 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 stated they have been requested to lie or commit fraud, of former sufferers who assert that they acquired poor care, and of regulators who’ve suspended licenses for some Younger-related services, saying they have been “dangerous to consumer well being and security resulting from important non-compliance with regulatory requirements.”
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 in opposition to the licenses.
In the event you’re having a slight sense of deja vu, it could be as a result of now-defunct Sovereign Well being had the same suit-and-countersuit tussle with insurer Well being Web 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 therapy for weak sufferers or the grasping, manipulative therapy 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 Web received large, with $45 million in damages and curiosity in opposition to Sovereign.
‘Love and acceptance’
The countersuit paints Younger’s operations in a saintly mild. In contrast to many different therapy services, Younger’s are keen to deal with homeless folks, these with habits points, prior convictions or different legislation enforcement historical past that “fancier” suppliers would possibly flip away, the countersuit stated.
“Suppliers thus distinguish themselves within the therapy group by their various consumer base and philosophy of affection and acceptance, not judgment,” the countersuit stated. They supply high-quality, invaluable companies, and Aetna’s actual gripe is that they offered “an excessive amount of healthcare to too many addicted Aetna enrollees,” the countersuit stated.
The insurer “cynically and unscientifically” conflates a number of therapy episodes, that are frequent within the restoration course of, with fraud, the countersuit stated. However relapse is a standard actuality and one of many standards used to diagnose substance use dysfunction, it stated.
“Aetna’s assumptions are harmful and fallacious,” the countersuit stated. “Restoration is a steady, nonlinear course of for many. Recovering addicts typically require life-long help to remain sober. Aetna doesn’t wish to cope with such complexity and its value. It could want if another person paid to maintain addicted people protected and sober. It’s that straightforward.”
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 evaluate’ 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 countless and repetitive audit processes main nowhere.”
“Aetna is aware of that erecting obstacles to dependancy therapy will lead to much less therapy, that means much less value to Aetna and plan sponsors,” the countersuit stated. “However addicted people who obtain much less therapy usually tend to fall deeper into dependancy, to surrender on restoration altogether, to lose their jobs…. They’re at better danger of turning into houseless and even dying. They’re an issue for presidency healthcare, for first responders, and for native 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 legislation violations, the countersuit stated. Solely then did they be taught of Aetna’s “physique brokering” fees – which have been alleged when the services had completely different homeowners and with out proof, it stated.
“Aetna’s insurance policies and practices (1) stigmatize and blame the sufferer and helping supplier, (2) mischaracterize relapse as inherently fraudulent, (3) mischaracterize repeated remedies or ‘extended’ remedies as inherently fraudulent, (4) mischaracterize programs of therapy in extra of per week or two as inherently fraudulent, and (5) mischaracterize Suppliers’ lawful actions facilitating entry to therapy for addicted people as inherently fraudulent or unlawful,” the countersuit stated.
Aetna’s actions have devastated Younger’s companies and attracted unwarranted scrutiny from different insurers, the countersuit stated. And the insurer isn’t any angel: The state has taken 191 enforcement actions in opposition to Aetna Well being of California since 2001, together with fines for failure to offer protection for medically essential psychological well being therapy, failure to offer clear written clarification of denials, and never contesting claims inside required time frames, the counterclaim stated.
“Aetna’s practices doubtless contribute to elevated and extended struggling, and even demise, of enrollees affected by dependancy,” the countersuit stated.
Younger calls for a jury trial and seeks to get well damages, curiosity, attorneys’ charges and bills.
Initially Printed: December 3, 2024 at 8:35 AM PST
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