James instructed his doctor-clients to schedule elective surgeries through the emergency room to ensure substantially higher reimbursement rates from insurance companies
A man from New York has been sentenced to 12 years in prison and ordered to pay over $336 million in restitution for participating in a fraudulent scheme that spanned several years. Along with his co-conspirators, including physicians across the country, the individual, Mathew James, orchestrated a scheme that defrauded multiple health insurance companies, resulting in losses amounting to hundreds of millions of dollars.
Court documents and trial evidence revealed that Mathew James, aged 54 and residing in East Northport, operated medical billing companies providing services to physicians, primarily specializing in plastic or orthopedic surgery throughout the United States.
James, acting as a third-party medical biller, submitted claims to insurance companies, occasionally seeking reconsideration or appeals for denied claims. He typically earned a percentage of the amount paid by the insurance companies. The evidence presented showed that James billed for procedures that were either more serious or entirely different than those performed by his doctor-clients.
Additionally, he engaged in thousands of calls impersonating patients and their relatives, persuading insurance companies to reconsider denied claims or increase payments on approved claims. This resulted in tens of millions of dollars in additional reimbursement to his doctor-clients, from which he received a percentage of the ill-gotten gains.
Furthermore, James instructed his doctor-clients to schedule elective surgeries through the emergency room to ensure substantially higher reimbursement rates from insurance companies. When insurers rejected these inflated claims, James impersonated patients, demanding that outstanding balances, often totaling tens or hundreds of thousands of dollars, be paid by the insurance companies.
James was convicted by a federal jury on July 13, 2022, on charges including health care fraud, conspiracy to commit health care fraud, wire fraud, and aggravated identity theft.
Acting Assistant Attorney General Nicole M. Argentieri of the Justice Department’s Criminal Division, U.S. Attorney Breon Peace for the Eastern District of New York, and Assistant Director in Charge James Smith of the FBI New York Field Office made the announcement.
The Fraud Section leads the Criminal Division’s efforts to combat health care fraud through the Health Care Fraud Strike Force Program. Since March 2007, the program, currently comprised of nine strike forces operating in 27 federal districts, has charged more than 5,400 defendants who collectively have billed federal health care programs and private insurers more than $27 billion. Additionally, the Centers for Medicare & Medicaid Services, working in conjunction with the Department of Health and Human Services
Office of Inspector General, are taking steps to hold providers accountable for their involvement in health care fraud schemes. More information can be found at www.justice.gov/criminal-fraud/health-care-fraud-unit.
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