Acting U.S. Attorney Announces $5 Million False Claims Act Settlement With Providers Of Programs For Adults With Developmental Disabilities

Matthew Podolsky, the Acting United States Attorney for the Southern District of New York, and Naomi Gruchacz, the Special Agent in Charge of the New York Regional Office of the Department of Health and Human Services, Office of Inspector General (“HHS-OIG”), announced today that the United States has filed and simultaneously settled a civil fraud lawsuit against COMMUNITY OPTIONS, INC. (“COI”) and COMMUNITY OPTIONS NEW YORK, INC. (“CONY”, and together with COI, the “Defendants” or “Community Options”).

CONY is a New York not-for-profit corporation that, among other things, operates a network of residential and non-residential facilities and programs for adults with developmental or intellectual disabilities throughout the State of New York. As part of its operations, CONY provides Day Habilitation services—which are programs intended to help adults with developmental or intellectual disabilities improve their independence and skills in daily activities. COI is a New Jersey not-for-profit corporation that, among other things, oversees CONY’s operations in New York and provides administrative support, including a centralized billing team that handles CONY’s submission of claims for reimbursement to the New York Medicaid Program. The settlement resolves claims that the Defendants fraudulently billed Medicaid by submitting claims for Day Habilitation services that did not meet applicable requirements, and improperly avoiding the return of overpayments received from the Medicaid program for Day Habilitation services that failed to meet those requirements.

Under the settlement agreement approved today by U.S. District Judge Valerie E. Caproni, the Defendants will pay the U.S. $2,148,540.37 and have admitted and accepted responsibility for certain conduct alleged in the Complaint as further described below. The Defendants have also agreed to pay $2,868,085.74 to the State of New York to resolve the State of New York’s claims, for a total recovery of $5,016,626.11.

In connection with the settlement agreement, the Defendants have also entered into a Corporate Integrity Agreement with HHS-OIG. The Corporate Integrity Agreement requires that the Defendants maintain a compliance program designed to foster adherence to federal health care program requirements and thereby protect the programs, and that they engage an independent organization to review claims they submit to Medicaid to ensure they comply with applicable requirements.

Acting U.S. Attorney Matthew Podolsky said: “Community Options billed Medicaid for services that failed to meet program requirements and retained potential overpayments received from Medicaid when it had an obligation to report and return those funds. Community Options has now admitted and accepted responsibility for its conduct. This Office will continue to ensure that our most vulnerable New Yorkers receive the services they deserve, and that our federal health care programs are protected against fraud and abuse.”

HHS-OIG Special Agent in Charge Naomi Gruchacz said: “Individuals and entities that participate in the federal healthcare system are required to obey the laws meant to preserve the integrity of program funds and the provision of appropriate services to patients. The settlement in this case involves a provider that is responsible for a vulnerable population, for which it should be prioritizing quality services.”

As alleged in the Complaint filed in Manhattan federal court:

In order to receive payment from the New York Medicaid Program for the provision of Day Habilitation services, COI was required to ensure that such services were delivered and documented in compliance with applicable program requirements promulgated by the New York State Office for People With Developmental Disabilities (the “OPWDD Requirements”).

However, between January 1, 2017, and September 13, 2024, (the “Relevant Period”), COI failed to maintain adequate policies concerning the provision and documentation of Day Habilitation services consistent with the OPWDD Requirements and failed to adequately train their employees on compliance with the OPWDD Requirements. As a result, COI’s employees failed to document CONY’s provision of Day Habilitation services in accordance with the OPWDD requirements.

COI understood that they were prohibited from submitting claims for reimbursement to New York’s Medicaid program for Day Habilitation services if the OPWDD Requirements were not met. Nonetheless, COI frequently submitted claims to Medicaid for Day Habilitation services that did not meet these requirements.

COI further understood that, as a provider of services under New York’s Medicaid Program, they were required to report and return identified overpayments to the New York Medicaid Program. During the Relevant Period, COI conducted non-routine reviews that identified their receipt and retention of Medicaid overpayments associated with Day Habilitation services. Nevertheless, COI failed to report and return those overpayments to the New York Medicaid Program.

As part of the settlement, the Defendants admitted and accepted responsibility for certain conduct alleged by the U.S., including the following:

• In order to receive payment from the New York Medicaid Program for the provision of Day Habilitation services, the Defendants were required to ensure that such services were delivered and documented in compliance with the OPWDD Requirements.
• During the Relevant Period, the Defendants failed to maintain adequate policies concerning the provision and documentation of Day Habilitation services consistent with the OPWDD Requirements and failed to adequately train their employees on compliance with the OPWDD Requirements. As a result, the Defendants’ employees failed to document CONY’s provision of Day Habilitation services in accordance with the OPWDD Requirements.
• Nonetheless, the Defendants submitted claims for, and received, reimbursement from the New York Medicaid Program for Day Habilitation services that did not meet OPWDD Requirements.
• CONY was required to report and return overpayments associated with Day Habilitation services that did not meet the OPWDD Requirements to the New York Medicaid Program. Nonetheless, when the Defendants conducted non-routine reviews that identified their receipt and retention of overpayments associated with Day Habilitation services, they failed to report and return those overpayments to the New York Medicaid Program. 

In connection with the filing of the lawsuit and settlement, the Government joined a private whistleblower lawsuit that had been filed under seal pursuant to the False Claims Act.

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Mr. Podolsky thanked both HHS-OIG for its investigative efforts and assistance with the case, and the Medicaid Fraud Control Unit at the New York State Attorney General’s Office for its collaboration in the resolution of this case.

The case is being handled by the Office’s Civil Frauds Unit.  Assistant U.S. Attorney David E. Farber is in charge of the case.