Optimus Health Care, Inc. paid $470,093.93 to resolve False Claims Act and state false claims allegations that it submitted Medicaid claims using incorrect Medicare denial codes causing Connecticut Medicaid to pay claims it would have denied, and improperly billed group therapy services for Qualified Medicare Beneficiaries who were not eligible for reimbursement.

Optimus Health Care, Inc. — FQHC Medicaid False Claims and Improper Billing (2023)

Outcome: Optimus Health Care, Inc., a federally qualified health center (FQHC) based in Bridgeport, Connecticut, paid $470,093.93 to resolve federal and state False Claims Act allegations that it submitted false claims to Connecticut Medicaid through improper billing practices for dual-eligible and Qualified Medicare Beneficiary (QMB) patients.

Optimus Health Care, Inc. operates 23 clinic locations in southwestern Connecticut providing primary care, dental, behavioral health, and other services to underserved populations. As a FQHC, Optimus received enhanced Medicaid reimbursement rates in exchange for serving Medicaid and low-income patients.

The government alleged two distinct billing violations covering conduct between January 2014 and December 2020. In the first, Optimus submitted claims to Connecticut Medicaid for dual-eligible beneficiaries — patients enrolled in both Medicare and Medicaid — using incorrect Medicare denial codes. The incorrect codes caused Medicaid to pay claims as primary payer that it would have denied or paid at a lower rate if the Medicare coordination-of-benefits information had been correctly submitted. In the second, Optimus improperly billed Connecticut Medicaid for group therapy services provided to QMB patients who were not eligible for reimbursement for those services under Medicaid rules.

The case was brought by a former Optimus employee who filed a qui tam lawsuit under the whistleblower provisions of the False Claims Act. The relator received $62,787.78 as her share of the federal recovery. The settlement was announced in August 2023 by the U.S. Attorney's Office for the District of Connecticut and the Connecticut Attorney General's Office. The federal government received $286,000 and the State of Connecticut received approximately $184,000 of the total settlement.

The case illustrates the compliance risk at FQHCs arising from coordination-of-benefits billing errors for complex patient populations, particularly dual-eligible and QMB populations where the rules governing payment responsibility between Medicare and Medicaid are technically demanding.

Primary Source: Federally-Qualified Health Center Pays $470K to Settle False Claims and Improper Billing Allegations — DOJ District of Connecticut