Optimus Health Care, Inc.
Outcome
Optimus Health Care Inc. settled for $470,093.93 to resolve allegations it submitted false claims to Connecticut Medicaid and received overpayments for ineligible services.
Details
Optimus Health Care, Inc. (Bridgeport, CT) — FQHC Medicaid False Claims
Outcome: Settled for $470,093.93 to resolve allegations of submitting false claims to Connecticut Medicaid and receiving overpayments for services ineligible under the FQHC payment system.
Optimus Health Care, Inc., a Federally-Qualified Health Center (FQHC) based in Bridgeport, Connecticut, submitted false claims to the Connecticut Medicaid program and received overpayments from Medicaid for ineligible services. FQHCs receive enhanced Medicaid reimbursement under a prospective payment system that requires services to meet specific encounter definitions — billing for ineligible services generates overpayments that must be returned.
The civil settlement of $470,093.93 was reached between Optimus, the federal government (represented by the U.S. Attorney for the District of Connecticut and HHS-OIG), and the Connecticut Attorney General's Office, announced August 9, 2023.
Primary Source: Federally-Qualified Health Center Pays $470K to Settle False Claims and Improper Billing Allegations
How Crucible Prevents This
Crucible's FQHC-specific billing compliance hooks would flag claims for services ineligible under the FQHC prospective payment system; a compliance gate verifying service eligibility against FQHC encounter definitions before submission would prevent billing for ineligible services generating Medicaid overpayments.
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