State Reaches Settlement in False Claims Act Lawsuit against Waterbury Behavioral Health Provider
The state has reached a $200,000 settlement with a Waterbury behavioral health clinician, along with two behavioral health practices he owns or controls, that resolves a lawsuit alleging the providers engaged in a long-term scheme to defraud Connecticut's Medicaid program. The settlement excludes these providers from participation in the Connecticut Medicaid program for a decade, Attorney General George Jepsen and state Department of Social Services (DSS) Commissioner Roderick L. Bremby said today.
Elijah Caldwell, a licensed clinical social worker, is the owner and operator of A Prospering Vision, LLC, and the founder and president of Home of Hope, Inc., both located in Waterbury. In a lawsuit filed in October 2017 brought under the Connecticut False Claims Act, the state alleged that, between March 2013 and December 2016, Caldwell billed the Connecticut Medical Assistance Program (CMAP) – which includes the state's Medicaid program – for claims for reimbursement for behavioral health services that purportedly were provided to CMAP patients at A Prospering Vision and Home of Hope.
The state alleged that many of the psychotherapy services billed by Caldwell to DSS either were never rendered to CMAP patients or were provided by unlicensed individuals, even though Caldwell submitted false claims for payment representing that Caldwell, a licensed behavioral health clinician had provided the services. The state further alleged that Caldwell had "upcoded" services provided to CMAP patients. The practice of upcoding occurs when a provider knowingly uses a higher-paying code on the claim form for a CMAP recipient to reflect the use of a more expensive service, procedure or device than was actually used or was medically necessary.
To resolve the litigation, Caldwell, A Prospering Vision and Home of Hope agreed to a $200,000 settlement and to be excluded from participation as providers in the CMAP for 10 years. The $200,000 settlement will be paid with $144,404.41 of payments to A Prospering Vision and Home of Hope that DSS suspended during the course of the investigation, and the remaining $55,595.59 will be paid directly by Caldwell. The entire $200,000 settlement amount will be returned to the state's Medicaid program.
"My office and our law enforcement partners are committed to protecting taxpayers and vigorously pursuing all those who knowingly submit false claims affecting the state's Medicaid program," said Attorney General Jepsen. "This settlement acknowledges the seriousness of the conduct alleged in this case and represents a fair resolution of the pending litigation."
"This settlement indicates the need for continued vigilance to safeguard the integrity of Medicaid as a public health coverage program," said Commissioner Bremby. "While cases like this do not represent medical providers as a whole, they need to be uncovered, investigated and resolved to protect Medicaid and taxpayers alike. DSS anti-fraud specialists worked closely with the Chief State's Attorney's and Attorney General's Offices in this investigation, and we commend all who took part."
This investigation in this case was initiated by a fraud referral from the DSS Office of Quality Assurance’s Special Investigations Unit and was conducted jointly with the state's Medicaid Fraud Control Unit (MFCU). Attorney General Jepsen and Commissioner Bremby thanked Connecticut's Chief State's Attorney Kevin Kane and his staff in the MFCU for their coordinated effort and action on this case.
Today's action is part of a larger effort by the State of Connecticut's Interagency Fraud Task Force, which was created in July 2013 to wage a coordinated and proactive effort to investigate and prosecute healthcare fraud directed at state healthcare and human service programs. The task force includes a number of Connecticut agencies and works with federal counterparts in the U.S. Attorney's Office and the U.S. Health and Human Services, Office of Inspector General – Office of Investigations For more information, please visit www.fightfraud.ct.gov.
Anyone with knowledge of suspected fraud or abuse in the public healthcare system is asked to contact the Attorney General's Antitrust and Government Program Fraud Department at 860-808-5040 or by email at firstname.lastname@example.org; the MFCU in the Office of the Chief State's Attorney at 860-258-5986 or by email at email@example.com; or the Department of Social Services fraud reporting hotline at 1-800-842-2155, online at www.ct.gov/dss/reportingfraud, or by email to firstname.lastname@example.org.
Assistant Attorney General Karla Turekian, Legal Investigator Peter Harrington and Assistant Attorney General Michael Cole, chief of the Antitrust and Government Program Fraud Department, assisted the Attorney General with this matter.
Please click here to view the settlement document.
Office of the Attorney General:
Jaclyn M. Severance
Department of Social Services: