Wallingford Pain Medicine Practice To Pay $1M In Medicaid Billing Settlement: AG

WALLINGFORD, CT — The state has reached a $1 million settlement with a Wallingford pain medicine practice that was accused of overbilling the Connecticut Medicaid program and violating the Connecticut False Claims Act, according to Connecticut Attorney General William Tong.

Tong announced Thursday the settlement with PCA Pain Care Center and its owner Benjamin Robinson.

The Attorney General’s Office began investigating PCA after the Department of Social Services identified “questionable billing pattens” that suggested PCA may have been overbilling the Connecticut Medicaid program, according to a news release.

Healthcare providers are required to submit claims for office visits to Medicaid that contain a billing code, known as a CPT code, that “accurately describes the services provided,” the news release states. The code determines how much Medicaid reimburses the provider.

The investigation “focused on whether starting in 2013, PCA ‘upcoded’ or used codes that would reimburse their office at a higher rate than PCA deserved when submitting claims for services they provided to patients,” according to the news release.

“My office will pursue any provider that overcharges Connecticut’s state Medicaid program or misuses resources intended for the care of our state’s most vulnerable residents,” Tong said in a statement. “This settlement provides recovery of damages from the overbilling and payment for post-settlement monitoring of PCA’s billing practices. The Office of the Attorney General takes seriously our responsibility to safeguard our public healthcare programs and is prepared to take strong action against anyone who violates that public trust.”

The settlement resolves the allegations that PCA and Robinson “submitted claims to Medicaid for their patients’ office visits that they knew, or should have known, were submitted with a billing code for a higher level of service than the services delivered by PCA’s providers merited,” the news release states.

Tong’s office accused PCA of coding nearly all its claims for its office visits with patients using the billing code for the “second most complex level of service that had the second highest reimbursement, regardless of the actual complexity of the service provided,” according to the news release.

“This $1 million settlement and related payment underscore that fact that Medicaid providers need to be completely honest and above-board in their claiming and billing practices,” DSS Commissioner Deidre S. Gifford said. “By and large, our enrolled providers are just that. Unfortunately, however, some outliers are subjects of fraud investigation and enforcement. I join Attorney General Tong in commending our professional staff and legal and law enforcement partners for detecting and resolving this case on behalf of Medicaid enrollees and taxpayers.”

As part of the settlement agreement, PCA and Robinson have paid $1 million. PCA has also paid an additional $45,000 to offset the expenses of any audits that DSS may conduct of claims PCA has or will submit to DSS for 2021, 2022, and 2023.

Anyone with knowledge of suspected fraud or abuse in the public healthcare system is asked to contact the Attorney General’s Antitrust and Government Program Fraud Department at 860-808-5040 or by email at ag.fraud@ct.gov; the Medicaid Fraud Control Unit at 860-258-5986 or by email at conndcj@ct.gov; the Department of Social Services fraud reporting hotline at 1-800-842-2155, online at www.ct.gov/dss/reportingfraud, or by email at providerfraud.dss@ct.gov, or by calling 1-800-HHS-TIPS.