This is the most ghoulish cynical capitalistic nightmare

Hope you’re ready to get really pissed off today my friends because this one is about greedy healthcare vampires fucking over people with mental health and addiction issues. Below I interview a lawyer bringing a class action suit against UnitedHealth who have routinely denied payment claims to patients whose insurance explicitly provided for such treatment for no other reason than fuck those people.

In March of this year a federal judge in California found that UnitedHealth Group had breached its duty to its patients by administering overly restrictive criteria in paying out claims that was based on financial concerns rather than the well-being of the people they were tasked with helping. A class action brought against United -- one of the largest health care providers in the country with revenues over $200 billion each year and profits around $12 billion -- claimed that they regularly denied mental and behavioral health benefit payments on behalf of patients who had insurance that was supposed to cover such treatment essentially because they didn’t want to pay for it. They wanted to keep the money and the patients could go get fucked more or less. The guys in finance were sitting in on the meetings and overriding the advice of the company’s doctors and mental health experts. You getting sober was not their problem. Go to a meeting they said.

“United Behavioral Health’s refusal to adopt the American Society of Addiction Medicine criteria was not based on any clinical justification," Joseph Spero the judge who presided over the case wrote in his finding. "Indeed, all of its clinicians recommended that the ASAM criteria be adopted. The only reason UBH declined to adopt the ASAM criteria was that its finance department wouldn't sign off on the change.”

In other words every cynical thought you have ever had about major healthcare companies doing everything they can to fuck you over is true.

What may or may not actually come from that regarding appeals remains to be seen but in the meantime a second class action suit — this time brought on behalf of the various mental health providers such as hospitals and therapists that were also left in the bag — has been filed this week.

“Plaintiffs, and the class they seek to represent, have not been paid for years’ worth of claims that were denied by UBH based on the now-discredited guidelines,” the new suit states. “In every case, Plaintiffs, in their professional judgment as licensed clinicians, determined that the services provided to their patients met generally accepted criteria and were medically necessary before UBH denied their claims.”

While the three named plaintiffs in the suit — Meridian Treatment Services, iRecover Treatment Inc. d/b/a Serenity Palms Treatment Center, and Harmony Hollywood Treatment Center — had 157 patients with over 2,000 collective claims denied in the period in question between 2011-2017 to the tune of around $5 million the suit estimates that given the size of United the class wide total of unpaid benefit claims may exceed $9.3 billion.

“In the face of the opioid epidemic, it is more important than ever that America’s health insurers stop placing profits over providers and do their part in mitigating the havoc that they facilitated, including by paying for the prescription opioids that precipitated this public health crisis,” Napoli Shkolnik PLLC the firm that has brought the class action suit said in a statement.

I spoke with Matthew Lavin a partner with the firm about why this sort of denial of coverage is the perfect exemplar of the rapacious greed in the for-profit health care industry and how given the multiple converging mental and behavioral health crises facing the country this sort of rat-fucking is particularly pernicious.

These sorts of things can be overwhelming and a little hard to understand for the average person which includes me so could you give us the entry into what is going on?

There was a trial and case that was decided in March of this year, Wit v. United Behavioral Health, that was decided on behalf of patients whose plans were subject to this federal law ERISA (Employee Retirement Income Security Act of 1974) which probably governs 50% of health plans in the U.S. The case was brought on behalf of patients who had ERISA plans that were denied behavioral health claims between 2011 and 2017. Patients who had to pay out of pocket. The court decided in that case that, essentially, the guidelines United had been using, until they just changed those guidelines this year, were basically designed by the financial department at UnitedHealth. They were designed not to provide the best care possible, just, literally, every single decision was Are we going to lose money if we pay this claim?

There was a law passed in 2008 called the Mental Health Parity Act that essentially required health insurers to cover behavioral health and addiction charges the same way they cover medical and surgical. So what they said in this trial is that United created these illegal guidelines, essentially so they wouldn’t have to pay claims. They realized that complying with this Parity Act was going to be super expensive.

So this claim we’re bringing is on behalf of healthcare providers, any place that does mental health like drug and alcoholic treatment centers, intensive outpatient treatment programs, psychiatrists, any provider, whether they’re a hospital or just some individual therapist, whose claims were denied and they haven’t been paid yet — that happens a lot, they just don’t get paid — on behalf of them against United. So all of those claims from 2011-2019 were all approved or denied under these faulty guidelines that United had created specifically to save money.

If you happen to have a very cynical overall impression of insurance companies, this confirms your suspicions right? It’s all about making money and not really helping people?

Yeah. It was pretty shocking. What was discovered during this trial is that they would have meetings… every insurance company has internal criteria that’s supposed to conform with generally accepted medical principals for when a claim is denied or not. It turned out that United was having these meetings to design its guidelines, and they were inviting in everyone from the finance department. So every time it was like How much is this going to cost us, if we covered this needed service, that the American Society of Addiction Medicine says we should cover? Essentially they were denying all claims for anything that wasn’t like acute detox for example. Inpatient treatment they weren’t going to cover it. They would send people letters saying Go to AA, good luck.

So it was like if you went in for a physical injury and they would stop the bleeding or set the bone or whatever, and then say ok you’re on your own the rest of the way?

Yeah. That’s what they would say. For behavioral health. We don’t think you’re going to benefit from treatment.

United realized, they saw the writing on the wall after that trial, and they immediately switched their guidelines to the generally accepted American Society of Addiction Medicine guidelines. The gold standard.

United is the largest health insurer in the country, they insure 30% of the commercial health insurance in this country, about eighty million people. They did this for eight years.

They do hundreds of billions in revenue per year.

I think last year was $280 billion.

So it’s not like they need to be cutting costs here.

No! They posted a 30% increase in profits every year for like the last four years. Another thing here is obviously there’s an opioid epidemic, and they were getting slammed with addiction claims that they didn’t see coming. Meanwhile they were also paying for prescriptions for people for OxyContin and everything. There were a lot of mental health crises and suicides and everything else in this country, and they responded to that, not like, Hey, what can we do to help people who are struggling people here? It was How do we make sure we don’t lose any money on this?

Can you describe the hypothetical patient they might be denying coverage to here?

Are you in Massachusetts? I’m from Massachusetts too. So imagine there’s some kid in Boston, he’s twenty years old, covered on his parents insurance, and he’s addicted to opiates and he fails out of college or whatever. Or he’s an IV heroin user and he needs treatment and shows up at a treatment center or hospital. They say we will detox you. Then they call up United and say we want to send this guy to residential treatment. And although he has the benefits United would say we don’t think you need treatment. We think you can go to a twelve stop meeting. Essentially they weren’t covering residential treatment for people. But if you were to read their insurance policies, it would say you have substance use disorder benefits that will pay for inpatient treatment.

That’s maddening. So if they already lost the original class action suit, what does yours do?

That was on behalf of patients. Let’s say they told me, Matt, we’re not going to pay for your treatment, and I was able to pay for it myself, that first lawsuit was about getting paid back for that. This lawsuit is a lot of people went to treatment, only to find out afterwards that they weren’t covered. That was the more common situation. The treatment centers or hospitals would see that they have the benefits — because you know United doesn’t get right back to you on a benefit decision — so they’d see you have benefits on the the face of your policy, and they would put them through treatment. Sometimes after that person was out of treatment United would deny it. They were doing this on a massive scale around the country, denying what they call sub-acute care.

So the patients were heroin addicts, alcoholics, and the mentally ill. These aren’t people who have sacks of cash to go pay the bill so the treatment centers, therapists, and hospitals were just eating it, for billons of dollars over the years.

United decided also that if we’re going to deny claims, the best people to deny claims to are alcoholics, drug addicts, and the mentally ill. They’re not real good at following up on their options. The chances of getting an appeal from one of them is close to zero.

Is that something they said explicitly in documents that were uncovered or are you just characterizing their general way of thinking?

That didn’t come out in the trial, but I do a lot of this stuff, representing health care providers with insurance companies all over the country and I see that a lot. They’re weighing risks. They’re like this is low risk for us to deny this because the odds of getting dinged on it… They also have death tables, and they say, you know what, in two or three years this person isn’t insured anymore. In two or three more years they’re probably not alive. Dead people can’t make claims.

This is the most ghoulish cynical capitalistic nightmare shit I’ve heard in a long time!

You know what’s amazing about it? Think about how much money is involved. Behavioral healthcare and psych treatment is really only about 5-10% of the entire medical expenses in the U.S. 90% is medical-surgical, cancer, heart stuff, broken bones, whatever. It would be like a rounding error for them to fix this. United is not going to lose money because they’re suddenly covering all this stuff. They’ll still make a profit. They may make less, but this is not a huge sector of the claims they pay every year.

Don’t take this the wrong way, but is your heart in this, or is it just a big case you think you can win?

I’ve got a lot of skin in this game. I’m a Boston Catholic Irish kid, oldest of eight kids. My whole family is from like Milton. I’ve been touched by a lot of alcoholism and addiction in my life. A lot of family members have suffered from this. Absolutely. I represent primarily addiction treatment providers and other behavioral health providers because it’s appalling to me how hard it is for them to get coverage. A lot of people don’t realize it. The law passed in 2008, The Mental Health Parity and Addiction Act, requires insurance companies to treat claims for addiction just like they’d treat claims for a broken leg, or cancer. They’re not going to kick you out of the hospital if you show up with stage 3 cancer.

Well they might...

The leading cause of death in the U.S. for adults age 18-50 right now is overdose. That’s amazing. Every twelve minutes somebody dies of an overdose in this country.

This overlaps with the whole gun issue as well. Everyone talks about how we have to focus on mental health and get people better treatment whenever there’s a gun massacre. The reality of it is that’s easier said than done.

It’s even harder for just psychiatric stuff than it is for addiction. United is also one of the worst for that. Private psychiatrists generally do not accept United insurance. Most psychiatrists, you hear about how they cost so much money, it’s because they do not take insurance, because of the difficulty they have getting claims through. You know how people complain like, oh, it’s $100, $200 bucks, whatever. And if they do take it they get paid almost nothing by the insurance companies.

Addiction treatment services are so much less than [physical ones]. I had my appendix out a couple years ago, and I saw the bill the hospital sent to the insurance company. It was $10,000 a day just to sit in the hospital. It didn’t include the anesthesiologist or the surgeon or anything else. Drug treatment is clinical, it doesn’t cost anything like that, and they still won’t cover it.

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