State Files False Claims Act Lawsuit against Waterbury Behavioral Health Provider
released on October 11, 2017
found in newsletter: October 2017
Attorney General George Jepsen and state Department of Social Services (DSS) Commissioner Roderick L. Bremby announced today that the state has filed a False Claims Act lawsuit against a Waterbury behavioral health provider alleging that he engaged in a long-term scheme to defraud the state’s Medicaid program.
The provider, Elijah Caldwell, is a licensed clinical social worker and is the owner and operator of A Prospering Vision LLC and the founder and president of Home of Hope, Inc., both located in Waterbury.
A Prospering Vision was enrolled in the Connecticut Medical Assistance Program (CMAP) – Connecticut’s Medicaid program – as a licensed behavioral health clinician group provider as well as for advanced practice registered nurse (APRN) group practice providers. Home of Hope, which represents itself as a nonprofit organization that serves as a one-year transitional housing program for homeless single women with children, was enrolled in the CMAP as a behavioral health provider.
In its complaint, the state alleges that, between March 2013 and December 2016, Mr. Caldwell billed the CMAP for millions of dollars in the form of claims for reimbursement for behavioral health services that purportedly were provided to CMAP patients. The state further alleges, however, that many of the services were never rendered, were provided by unlicensed individuals or were “upcoded.” The practice of upcoding occurs when a provider knowingly uses a higher-paying code on the claim form for a CMAP recipient to reflect the use of a more expensive service, procedure or device than was actually used or was medically necessary.
“Enforcement of the False Claims Act and protection of our taxpayer-funded healthcare programs continues to be a priority of my office,” said Attorney General Jepsen. “Skilled behavioral and mental health treatment is an essential service provided by the Medicaid program and has been proven to positively impact overall wellness while decreasing medical costs. This provider has compromised those services by allowing unskilled, unlicensed individuals to provide them to our Medicaid beneficiaries. My office and our law enforcement partners are committed to protecting the public and vigorously pursuing all those who knowingly submit false claims affecting the state’s Medicaid program.”
“This case is particularly serious because it alleges both provider fraud against taxpayers and improper treatment of patients through uncredentialed individuals,” said Commissioner Bremby. “State and federal agencies will continue to bring strong enforcement action against providers who defraud the public health coverage system and abuse the public trust. While those subject to enforcement do not represent Medicaid providers as a whole, anti-fraud investigation and actions protect the integrity of the program in Connecticut and nationally. I join Attorney General Jepsen in commending the work of our state and federal anti-fraud enforcement personnel, including staff in his office, the Chief State’s Attorney’s Office, and Department of Social Services investigators.”
The state alleges that Mr. Caldwell routinely billed the CMAP for 53 to 60 minutes of psychotherapy although, in many instances, patients had either cancelled or did not show up for the appointment. In some instances, patients were purported to have received behavioral health services but were actually incarcerated at the time, were inpatient in a hospital or another inpatient facility, or otherwise could not have received the services on the date claimed.
In other instances, Mr. Caldwell allegedly submitted claims purporting that he had provided psychotherapy service to a patient when, in fact, the service had been provided by an unlicensed person.
The state further alleged that Mr. Caldwell engaged in upcoding of services; in particular, the state alleges that Mr. Caldwell submitted claims for psychotherapy services provided by him when patients actually received medication management by an APRN. Medication management involves the prescribing, monitoring and changing of a patient’s drug prescriptions, and it is paid by Medicaid at a significantly lower rate than psychotherapy services.
The Office of the Chief State’s Attorney’s Medicaid Fraud Control Unit (MFCU) has executed a warrant for Mr. Caldwell’s arrest on charges of larceny and prescription drug fraud. The criminal charges are only allegations and not evidence of guilt; a defendant is presumed innocent unless and until proven guilty beyond a reasonable doubt.
Attorney General Jepsen thanked the Office of the Chief State’s Attorney Medicaid Fraud Control Unit as well as DSS’s Office of Quality Assurance Special Investigations Unit for their coordinated effort and action on this case.
Today’s action is part of a larger effort by the State of Connecticut’s Interagency Fraud Task Force, which was created in July 2013 to wage a coordinated and proactive effort to investigate and prosecute healthcare fraud directed at state healthcare and human service programs. The task force includes a number of Connecticut agencies and works with federal counterparts in the U.S. Attorney’s Office and the U.S. Health and Human Services, Office of Inspector General – Office of Investigations For more information, please visit www.fightfraud.ct.gov.
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 firstname.lastname@example.org; the MFCU in the Office of the Chief State’s Attorney at 860-258-5986 or by email at email@example.com; or the Department of Social Services fraud reporting hotline at 1-800-842-2155, online at www.ct.gov/dss/reportingfraud, or by email to firstname.lastname@example.org.
Assistant Attorney General Karla Turekian, Legal Investigator Peter Harrington and Assistant Attorney General Michael Cole, chief of the Antitrust and Government Program Fraud Department, are assisting the Attorney General with this matter.
Please click here to view a copy of the state’s complaint.
Original Press Release