Long Island Man Convicted of over $600 Million Health Care Fraud, Wire Fraud and Identity Theft Scheme

 

Defendant Impersonated Patients on Calls to Insurance Companies and Staged Fake Emergency Room Visits to Fraudulently Inflate Claims

 A federal jury in Central Islip returned a guilty verdict on eight counts of a superseding indictment charging Mathew James with perpetrating an over $600 million health care fraud scheme, which also included wire fraud and aggravated identity theft charges.  The verdict followed a six-week trial before United States District Judge Joanna Seybert.  

Breon Peace, United States Attorney for the Eastern District of New York, Kenneth A. Polite Jr., Assistant Attorney General of the Justice Department’s Criminal Division, and Michael J. Driscoll, Assistant Director-in-Charge, Federal Bureau of Investigation, New York Field Office (FBI), announced the verdict.

“The defendant stands convicted of carrying out an audacious scheme in which he used insurance companies like ATM machines.  He stole hundreds of millions of dollars until he was finally exposed by a paper trail a mile-long, phone recordings on which he impersonated patients, and text messages and emails with his co-conspirator doctor clients demonstrating his nefarious billing practices. For this massive fraud, a federal jury convicted him today,” stated United States Attorney Peace.  “Health care fraud is not a victimless crime, because fraudulent billing ultimately affects consumers who must pay the cost of higher insurance premiums.”

“James orchestrated a fraudulent medical billing scheme to steal from insurance companies and businesses, in order to line his own pockets,” said Assistant Attorney General Polite of the Justice Department’s Criminal Division. “This conviction shows that medical billers who fuel health care fraud will be brought to justice.”

As proven at trial, James operated medical billing companies to provide billing services for physicians, primarily plastic 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.  The evidence showed that James billed for procedures that were either more serious or entirely different than those his doctor-clients performed.  For example, the government presented evidence that James impersonated Jeff Pash, the National Football League’s general counsel, and Marcus Smart, a professional basketball player for the Boston Celtics of the National Basketball Association, in calls the defendant made to insurance companies in which he exaggerated medical procedures.  James made thousands of impersonation calls resulting in over 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.