Attorney General Tong Announces $470,000 Settlement with Optimus Health Care Over False Claims and Improper Billing Allegations(Hartford, CT) – Attorney General William Tong, the United States Attorney for the District of Connecticut, and the U.S. Department of Health and Human Services, Office of the Inspector General today announced that Optimus Health Care, Inc., a federally-qualified health center (“FQHC”) based in Bridgeport, has entered into a civil settlement agreement with the federal and state governments and has paid a total of $470,093.93 to resolve allegations that it submitted false claims to the Connecticut Medicaid program, and received overpayments from Medicaid for ineligible services.
Optimus Health Care, Inc. (“Optimus”) has 23 locations in southwestern Connecticut. As an FQHC, Optimus receives patient revenues and grants from the federal and state governments.
“Optimus Health Care repeatedly overbilled Connecticut’s Medicaid program, taking in payments they were ineligible to receive. I thank our federal partners at HHS-OIG and the U.S. Attorney’s Office for their coordination and assistance in protecting our public healthcare programs and tax dollars,” said Attorney General Tong.
The allegations against Optimus arise out of claims submitted to Connecticut Medicaid for dual-eligible beneficiaries. Dual-eligible beneficiaries are Medicare beneficiaries who are also eligible for Medicaid coverage. Some dual-eligible beneficiaries are eligible for, and receive, full Medicaid coverage in addition to their Medicare coverage. Other dual-eligible beneficiaries are known as Qualified Medicare Beneficiaries (“QMBs”). QMBs qualify for Medicaid to pay their Medicare co-pays, premiums, co-insurance, and deductibles.
The government alleges that Optimus submitted false claims to Connecticut Medicaid for dual-eligible beneficiaries with the incorrect Medicare denial codes. This caused Medicaid to pay claims it would have otherwise denied. The government also alleges that Optimus improperly billed Connecticut Medicaid for group therapy services for QMBs who were not eligible for reimbursement for those services.
To resolve its liability, Optimus paid $470,093.93 to the federal and state governments for conduct occurring between January 2014 and December 2020.
The False Claims Act allegations resolved by the settlement were originally brought in a lawsuit filed in the U.S. District Court in Connecticut by a relator, or whistleblower, under the qui tam provisions of the False Claims Act. These provisions allow private parties to bring suit on behalf of the government and to share in any recovery. The relator, a former employee of Optimus, will receive $62,787.78 as her share of the recovery. The case resolved by this settlement was captioned U.S. ex rel Migdalia Burgos, and the State of CT v. Optimus Health Care, Inc. (Docket No. 3:19-cv-652).
This matter was investigated by the Office of the Inspector General for the Department of Health and Human Services, and the Connecticut Office of the Attorney General. The case was prosecuted by Assistant U.S. Attorney Sara Kaczmarek and by Deputy Associate Attorney General Gregory O’Connell of the Attorney General’s Office. Legal Investigator Timothy Edwards also assisted the Attorney General in this matter.
Anyone with knowledge of suspected fraud or abuse in the public healthcare system is asked to contact the Attorney General’s Government Program Fraud Section at 860-808-5040 or by email at firstname.lastname@example.org; the Medicaid Fraud Control Unit 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.