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New York Man Sentenced to 12 Years for Massive Healthcare Fraud Scheme

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Medriva Correspondents
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New York Man Sentenced to 12 Years for Massive Healthcare Fraud Scheme

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A Massive Fraud Scheme Unveiled

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A New York man, Mathew James, has received a 12-year prison sentence and has been ordered to pay over $336 million in restitution for committing healthcare billing fraud, wire fraud, and identity theft. James ran a medical billing company that submitted fraudulent claims for services not performed by his physician clients. He also scheduled elective surgeries in emergency rooms to secure higher reimbursements. Additionally, James impersonated patients, including NBA point guard Marcus Smart, in an attempt to communicate with insurance companies and get disputed claims approved.

The Scope of the Fraud

James operated medical billing companies providing services for physicians, primarily plastic surgeons across the nation. He used these companies to carry out a massive scheme to defraud insurance companies, resulting in the loss of hundreds of millions of dollars. The scheme involved thousands of impersonation calls, leading to tens of millions in additional reimbursement to James's doctor-clients, from which he received a percentage of the fraudulent proceeds.

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Details of the Fraudulent Activities

As a medical biller, James used several fraudulent strategies to increase insurance payouts. He had doctors schedule elective surgeries via emergency rooms to inflate insurance reimbursement rates. He also billed for procedures that were different from those actually performed. When insurance companies rejected these claims, he impersonated outraged patients or policyholders to demand payment. Among his impersonation victims were NBA player Marcus Smart and NFL lawyer Jeff Pash.

The Impact on the Victims

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Several victims of James's impersonation testified during the trial. NBA player Marcus Smart expressed his distress over the impersonation, fearing it could damage his reputation as a role model. On the other hand, NFL lawyer Jeff Pash was unaware of the impersonation until federal agents informed him. James's lawyer attributed his actions to a drinking problem and stress from work and familial responsibilities, claiming that these calls were an aberration in his client's otherwise caring and decent life.

The Aftermath and Punishment

Matthew James of East Northport, N.Y., was convicted by a federal jury in July 2022. The court sentenced him to 12 years in prison and ordered him to pay over $336 million in restitution for his fraudulent activities. He was charged with healthcare billing fraud, wire fraud, and identity theft. The verdict has underlined the severity of the charges and the repercussions for such fraudulent actions. Notably, the fraud led to inflated medical costs for patients and resulted in higher insurance premiums for the public.

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