Legal Pointers

Scheduling elective surgeries through the ER is Fraud

Posted by Ben Mirza | Jul 14, 2022

Healthcare whistleblower - Fraud through performing emergency cases

Case involving scheme to perform elective surgeries through the emergency room for higher reimbursements from insurance companies.  

Here are news from the DOJ:

JUSTICE NEWS

Department of Justice
Office of Public Affairs

FOR IMMEDIATE RELEASE
Wednesday, July 13, 2022

Jury Convicts Man of $600 Million Health Care Fraud, Wire Fraud, and ID Theft Scheme

A federal jury convicted a New York man today in an over $600 million health care fraud, wire fraud, and identity theft scheme.

According to court documents and evidence presented at trial, Mathew James, 54, of East Northport, operated a medical billing company that billed for procedures that were either more serious or entirely different than those James' doctor-clients performed.  James 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.

“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 Kenneth A. Polite, Jr. of the Justice Department's Criminal Division. “This conviction shows that medical billers who fuel health care fraud will be brought to justice.”          

“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,” said U.S. Attorney Breon Peace for the Eastern District of New York. “Health care fraud is not a victimless crime, because fraudulent billing ultimately affects consumers who must pay the cost of higher insurance premiums.”

“Health care fraud, including fraudulent billing schemes like this, costs U.S. taxpayers tens of billions of dollars annually. These crimes impact all of us in many ways, including increased health insurance premiums, greater out-of-pocket expenses and copayment amounts for medical treatment, and reduced or lost benefits, just to name a few,” said Assistant Director Luis Quesada of the FBI's Criminal Investigative Division. “The FBI, together with our law enforcement partners, is committed to rooting out health care fraud in all its forms and bringing those who seek to exploit our health care system to justice.”

James was convicted of conspiracy to commit health care fraud, health care fraud, three counts of wire fraud, and three counts of aggravated identity theft. He is scheduled to be sentenced at a later date and faces up to 10 years in prison for health care fraud conspiracy, up to 10 years in prison for health care fraud, up to 20 years in prison for each of three wire fraud counts, and a two year mandatory minimum each for three aggravated identity theft counts. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors.

If you are seeing something similar occurring at work, whether you are the provider, the company, the owner,  or the employee, or even a potential whistleblower call us for a free and confidential consult, and put our team to work for you. 

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