March 29, 2016

Company involved in behavioral health shakeup faces suits

Joe Gratz


The company responsible for oversight of the 15 behavioral health providers that lost funding for alleged Medicaid fraud is now itself facing lawsuits over alleged fraud.

OptumHealth faces three lawsuits over alleged malfeasance in its contract with the state to oversee the state’s Medicaid program.

Of the 15 companies that the state Human Services Department, citing an audit by Public Consulting Group, said had “credible allegations of fraud” already 13 have been exonerated by the state Attorney General after investigations.

It was Optum’s efforts to root out alleged fraud and waste that led to the shakeup. The shakeup included the state bringing in Arizona companies to take over for the New Mexico providers that no longer had funding to continue, some of which have went out of business.

The Santa Fe New Mexican reported on the lawsuits on Tuesday.

One of the lawsuits would be familiar to NM Political Report readers. Earlier this year, NM Political Report reported on a lawsuit by former Optum employee Karen Clark.

Karen Clark, who worked as a senior investigator for a branch of UnitedHealth Group from October 2011 through April 2012, filed a lawsuit accusing Optum Behavioral Health Solutions of giving Medicaid payments to reimburse nearly $14 million in false claims by nine health providers. Clark also alleges that Optum took home 28 percent of the wrongly reimbursed Medicaid claims.

Clark said that when she brought up the alleged fraud to superiors, she was told to back off.

The New Mexican outlined a lawsuit by Valerie Tafoya. She was once the senior fraud investigator at Optum and says when she found $4 million in possible Medicaid billing errors, she was told to keep quiet.

She did not and says she instead went to the Attorney General’s office; she says she was then fired.

A third lawsuit is from one of the Arizona companies brought in to fill the coverage gap created by the funding freeze for the 15 new Mexico providers.

From the New Mexican:

La Frontera Center Inc. alleges OptumHealth and other UnitedHealth Group subsidiaries had accused providers of fraud to cover up their own inability to pay Medicaid claims to those providers. The companies have asked to halt the lawsuit in favor of arbitration.

Optum told the New Mexican there was no wrongdoing in the Tafoya or Gonzales cases.