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Man Jailed For $336M Health Insurance Fraud

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The Department of Justice has prosecuted three men over the fraud of TRICARE

A man has been jailed for 12 years and ordered to pay a staggering $336 million in restitution for a long-term fraud scheme targeting health companies.

Matthew James, 54, of East Northport, New York, operated medical billing companies which worked on behalf of physicians.

He used the companies to carry out a massive scheme to defraud insurance companies.

As a third-party medical biller, James submitted claims to insurance companies.

When necessary, he requested reconsideration or appeals of denied claims.

This meant he typically earned a percentage of the amount paid by the insurance companies.

But the evidence showed James billed for procedures that were either more serious or entirely different than those his doctor-clients performed.

James also made thousands of calls where impersonated patients and patients’ relatives.

Thiss was to induce insurance companies to reconsider denied claims or pay more on approved claims.

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This resulted in tens of millions of dollars in additional reimbursement to his doctor-clients.

James would then receive a percentage of the fraudulent proceeds.

James also told his doctor-clients to schedule elective surgeries through the emergency room.

This meant insurance companies would have to reimburse at substantially higher rates.

If insurance companies denied the inflated claims, James impersonated patients to force the insurance companies to pay the outstanding balances of tens or hundreds of thousands of dollars.

The charges

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.

Acting Assistant Attorney General Nicole M. Argentieri of the Justice Department’s Criminal Division, U.S. Attorney Breon Peace for the Eastern District of New York, and Assistant Director in Charge James Smith of the FBI New York Field Office made the announcement.

The FBI investigated the case.

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