Penalty Amount
$1,000,000
The Connecticut Attorney General settled with PCA Pain Care Center and its owner for overbilling Medicaid by using higher billing codes than warranted for services provided. They paid $1 million to resolve allegations under the Connecticut False Claims Act.
PCA and Robinson paid $1 million and an additional $45,000 to offset future audit expenses, and agreed to post-settlement monitoring of billing practices.
In-house legal teams should review all provider-payor agreements, including Medicaid managed care contracts, commercial insurer participation agreements, and any third-party administrator (TPA) arrangements. Focus on clauses governing billing and coding compliance, representations and warranties regarding claim accuracy, indemnification for false claims, audit rights, and termination for regulatory violations. Specific attention is needed for provisions that incorporate by reference payer billing manuals, CPT coding guidelines, and state/federal healthcare program rules. Changes may be required to add mandatory coder training certifications, implement pre-submission coding review protocols, strengthen audit cooperation terms, and clarify liability for overpayments resulting from upcoding or misrepresentation of service levels.
Entity
Robinson PA, LLC d/b/a PCA Pain Care Center
Also known as: PCA Pain Care Center
Industry
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$400.0M
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