A New York man was sentenced to 12 years in prison for his role in a scheme that defrauded multiple health insurance companies out of more than $336 million.
To facilitate his scheme, Mathew James, 54, of East Northport, operated companies providing billing services to physicians throughout the U.S. as a third-party medical biller, according to a Feb. 2 news release from the Justice Department. Mr. James billed insurance companies for procedures that were either more serious or entirely different than those performed by his physician partners and directed his physician-clients to schedule elective surgeries through the emergency room so insurance companies would reimburse at higher rates.
According to the Justice Department, Mr. James also made thousands of calls while impersonating patients and patients' relatives to persuade insurance companies to reconsider denied claims or pay more on approved claims, including calls in which he claimed to be Jeff Pash, general counsel of the NFL, and Marcus Smart, an NBA player with the Boston Celtics.
These fraudulent claims resulted in "hundreds of millions" of additional reimbursement to his clients, from which he received a percentage of the fraudulent proceeds, according to the release.
Mr. James was sentenced to 10 years on the fraud charges and two years for the aggravated identity theft charges and also ordered to pay $336,996,416.85 in restitution and forfeit $63,382,049.02.