CT’s Optimus Health Care agrees to pay nearly $500K to settle false billing claims [Hartford Courant]

Optimus Health Care, a leading primary care provider in Fairfield County, has agreed to pay nearly half a millions dollars to the state and federal governments to resolve a complaint that it padded its bottom line with fraudulent Medicaid and Medicare billings.

The civil settlement disclosed Wednesday is the result of a whistleblower complaint in 2019 by a former Optimus employee who accused the company of manipulating Medicare and Medicaid billings to mitigate losses when patients with dual coverage were denied treatment.

The whistleblower will collect about $63,000 from the settlement under the terms of the federal false claims act.

Optimus has 23 locations in southwestern Connecticut and receives funding from the federal and state governments.

The whistleblower complaint turned on claims by Optimus to Connecticut Medicaid for patients eligible for benefits under both the Medicaid and Medicare programs.

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 and qualify for Medicaid to pay their Medicare co-pays, premiums, co-insurance, and deductibles.

Optimus was accused of including incorrect Medicare denial codes on what amounted to false claims to Connecticut Medicaid for dual-eligible beneficiaries. That caused Medicaid to pay claims it would have otherwise denied.

In addition, Optimus was accused of improperly billing Connecticut Medicaid for group therapy services for ineligible beneficiaries.

Optimus agreed to pay $470,093.93 to the federal and state governments for conduct between January 2014 and December 2020.

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