Published: 1:00 pm, Wed. Mar. 30th, 2016Updated: 1:29 pm
A health care company that tried to root out fraud in New Mexico’s Medicaid program has now been accused of committing Medicaid fraud itself.
Three lawsuits filed against OptumHealth Inc. this year accuse the company of malfeasance stemming from its state contract to oversee Medicaid payments to mental health providers between July 2009 and December 2013, the Santa Fe New Mexican reported.
OptumHealth spokeswoman Lauren Mihajlov says the company rejects the allegations in all three lawsuits and “will defend ourselves vigorously.”
OptumHealth’s efforts led Gov. Susana Martinez’s administration in June 2013 to suspend payments to 15 providers treating low-income patients for mental illness or addiction. Three years later, 13 of the 15 providers have been exonerated of criminal wrongdoing by the state Attorney General’s Office.
In the latest lawsuit, a former OptumHealth investigator says she was fired for reporting concerns about possible Medicaid fraud on the company’s part to the Attorney General’s Office. Valerie Tafoya says OptumHealth had told her to keep quiet after discovering $4 million in potential Medicaid billing errors.
Tafoya first sued the company in May 2012, but the case was under a court-ordered seal for more than three years at the request of the Attorney General’s Office. On March 18, Tafoya filed an amended suit against OptumHealth under the Fraud Against Taxpayers Act.
Her complaint names OptumHealth, former Chief Executive Officer Michael Evans and former Chief Operating Officer Marilyn Van Horn as defendants. She says the company’s higher-ups told her not to investigate certain improper billing practices and that her boss, Van Horn, did not want to ruffle feathers with certain providers who were politically connected. Neither Evans nor Van Horn could be reached for comment.
The New Mexico Fraud Against Taxpayers Act allows whistleblowers who expose money fraudulently obtained from the state to recover up to 25 percent of the money returned to the state.
“With regards to the Tafoya complaint, we investigated as soon as we learned of allegations of employee misconduct, took prompt action based on our findings as to her employment and disclosed the results of our investigation and actions to the New Mexico Attorney General’s Office and the New Mexico Behavioral Health Collaborative,” Mihajlov said.
Former OptumHealth employee Karen Clark is also suing the company on allegations similar to Tafoya’s. Attorneys for Minnesota-based insurance giant UnitedHealth Group, OptumHealth’s parent company, have filed a motion to dismiss Clark’s suit. They say she cannot produce evidence of false claims.
The third suit was filed by an Arizona company recruited to provide some New Mexico patients with mental health treatment after Martinez’s administration cut off provider payments. La Frontera Center Inc. argues that Optun Health and other UnitedHealth Group subsidiaries 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 and instead go to arbitration.