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. 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.
