Press Releases
03/17/2022
Attorney General Tong Announces $1 Million Settlement with Wallingford Pain Medicine Practice Over Overbilling Allegations
(Hartford, CT) — Attorney General William Tong today announced a $1 million settlement with Robinson PA, LLC d/b/a PCA Pain Care Center (PCA) and its owner Benjamin Robinson to resolve allegations that they overbilled the Connecticut Medicaid program and violated the Connecticut False Claims Act.PCA is a pain management practice in Wallingford, Connecticut. The Office of the Attorney General initiated an investigation after a referral from the Department of Social Services. DSS had identified some questionable billing patterns that suggested PCA may have been overbilling the Connecticut Medicaid program.
Healthcare providers must submit claims for office visits to Medicaid that contain a billing code, known as a CPT code, that accurately describes the services provided. This code determines how much Medicaid reimburses the provider. The Office of the Attorney General’s investigation focused on whether starting in 2013, PCA “upcoded” or used codes that would reimburse their office at a higher rate than PCA deserved when submitting claims for services they provided to patients.
The settlement resolves the allegations that PCA and Robinson submitted claims to Medicaid for their patients’ office visits that they knew, or should have known, were submitted with a billing code for a higher level of service than the services delivered by PCA’s providers merited. The Office of the Attorney General alleged that PCA coded nearly all its claims for its office visits with patients using the billing code for the second most complex level of service that had the second highest reimbursement, regardless of the actual complexity of the service provided.
“My office will pursue any provider that overcharges Connecticut’s state Medicaid program or misuses resources intended for the care of our state’s most vulnerable residents. This settlement provides recovery of damages from the overbilling and payment for post-settlement monitoring of PCA’s billing practices. The Office of the Attorney General takes seriously our responsibility to safeguard our public healthcare programs and is prepared to take strong action against anyone who violates that public trust,” Attorney General Tong said.
“This $1 million settlement and related payment underscore that fact that Medicaid providers need to be completely honest and above-board in their claiming and billing practices,” DSS Commissioner Deidre S. Gifford said. “By and large, our enrolled providers are just that. Unfortunately, however, some outliers are subjects of fraud investigation and enforcement. I join Attorney General Tong in commending our professional staff and legal and law enforcement partners for detecting and resolving this case on behalf of Medicaid enrollees and taxpayers.”
As part of the settlement agreement, PCA and Robinson have paid $1 million. PCA has also paid an additional $45,000 to offset the expenses of any audits that DSS may conduct of claims PCA has or will submit to DSS for 2021, 2022, and 2023.
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 ag.fraud@ct.gov; the Medicaid Fraud Control Unit at 860-258-5986 or by email at conndcj@ct.gov; the Department of Social Services fraud reporting hotline at 1-800-842-2155, online at www.ct.gov/dss/reportingfraud, or by email at providerfraud.dss@ct.gov, or by calling 1-800-HHS-TIPS.
Forensic Fraud Examiner Thomas Martin, Forensic Fraud Examiner Kevin Jeffko, Legal Investigator Timothy Edwards, Assistant Attorney General Richard Porter and Jeremy Pearlman, Chief of the Antitrust and Government Program Fraud Department assisted the Attorney General in this matter.
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Media Contact:
Elizabeth Benton
elizabeth.benton@ct.gov
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