Mathew James, $600M Health Care Fraud, New York 2022

A New York man has been sentenced to 12 years in prison and ordered to pay over $336 million in restitution for a years-long fraud scheme in which he and his co-conspirators, including physicians throughout the country, defrauded multiple health insurance companies out of hundreds of millions of dollars.

According to court documents and evidence presented at trial, Mathew James, 54, of East Northport, operated medical billing companies to provide billing services for physicians — primarily plastic or orthopedic surgeons throughout the United States — and used his companies to carry out a massive scheme to defraud insurance companies.

As a third-party medical biller, James submitted claims to insurance companies and, when necessary, requested reconsideration or appeals of denied claims, typically earning a percentage of the amount paid by the insurance companies. The evidence showed that James billed for procedures that were either more serious or entirely different than those his doctor-clients performed.

In addition, James made thousands of calls in which he impersonated patients and patients’ relatives to induce insurance companies to reconsider denied claims or pay more on approved claims, resulting in tens of millions of dollars in additional reimbursement to his doctor-clients and from which he received a percentage of the fraudulent proceeds.

James also directed his doctor-clients to schedule elective surgeries through the emergency room so that insurance companies would reimburse at substantially higher rates. When insurance companies denied the inflated claims, James impersonated patients to demand that the insurance companies pay the outstanding balances of tens or hundreds of thousands of dollars.

A federal jury convicted James on July 13, 2022, of health care fraud, conspiracy to commit health care fraud, wire fraud, and aggravated identity theft.

James, a resident of East Northport, New York, must pay over $336 million in restitution for his role in the scheme.

Source: https://www.justice.gov/archives/opa/pr/man-sentenced-336m-health-care-fraud-wire-fraud-and-identity-theft-scheme