Mathew James was sentenced today by United States District Judge Joanna Seybert to 12 years in prison for a massive health care fraud scheme in which he and his co-conspirators, including physicians throughout the country, defrauded multiple health insurance companies out of hundreds of millions of dollars. James was sentenced to 10 years on the fraud charges and two years to be served consecutive on the aggravated ID theft charges. The Court also ordered restitution in the amount of $336,996,416.85 and forfeiture of $63,382,049.02.
Breon Peace, United States Attorney for the Eastern District of New York, Nicole M. Argentieri, Acting Assistant Attorney General of the Justice Department’s Criminal Division, and James Smith, Assistant Director-in-Charge, Federal Bureau of Investigation, New York Field Office (FBI), announced the sentence.
“James went to great lengths to carry out a complex fraud scheme that caused insurance companies to pay hundreds of millions of dollars in fraudulent claims,” stated United States Attorney Peace. “The defendant not only falsified medical records and forged signatures, but also brazenly impersonated patients and their family members, all of which justifies a significant jail sentence to deter others from such audacious conduct.”
“Today, Mathew James was justly punished with a lengthy sentence in prison for his immense and brazen health care fraud scheme. James took extreme steps to carry out his more than half-billion-dollar fraud – faking signatures, impersonating well known figures in the world of sports, and utilizing fraudulent documents,” stated FBI Assistant Director-in-Charge Smith. “The FBI will continue to take the lead in investigating and holding accountable anyone attempting to illegally profit from deceptive and fraudulent health care schemes.”
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. 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 then of 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.
Assistant U.S. Attorneys Catherine Mirabile and Antoinette N. Rangel of the Eastern District of New York, and Trial Attorney Miriam Glaser Dauermann of the Justice Department’s Fraud Section are prosecuting the case. Assistant U.S. Attorney Tanisha Payne of the Eastern District of New York’s Asset Recovery Section is handling forfeiture matters.