Federally-Qualified Health Center Pays $470K to Settle False Claims and Improper Billing Allegations

The United States Attorney for the District of Connecticut, the U.S. Department of Health and Human Services, Office of the Inspector General, and the Connecticut Attorney 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.

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.

People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Task Force at (203) 777-6311.