From time to time, the Allegiant Experts Blog will discuss the topic of medical billing errors. We’ve made efforts to list ways to spot medical billing errors. Suggested steps include keeping records of all contacts with health care providers; requesting itemized copies of all bills; and getting all promises in writing.
As well, our blog has offered advice on how to avoid medical billing errors. Among our tips were eliminating inadvertent upcoding or undercoding; verifying changes to patients’ insurance plans; checking for mismatches in patient information; double checking all information; and avoiding double billing.
Of course, none of this advice matters to those who purposely work to defraud our nation’s insurance programs. For fraudsters, medical billing errors are done on purpose.
New York man found guilty of purposeful medical billing errors.
Enter 54 year-old, Matthew James. The East Northport, New York resident was recently convicted in a health care fraud scheme worth over $600 million. Guilty of health care fraud, wire fraud and identity theft, James was the operator of a medical billing company. As reported by the United States Department of Justice yesterday, James used his company to submit bogus bills.
They were 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,” reports the DoJ.
Insurance companies originally denied the large claims.
According to the DoJ report, when insurance companies denied James’ inflated claims, he took his fraudulent actions to the next level. James impersonated patients to demand that the insurance companies pay the outstanding balances. The amounts were in the tens or hundreds of thousands of dollars.
In total, 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. His sentencing is forthcoming. The maximum sentences James can receive are 10 years in prison for health care fraud conspiracy, 10 years in prison for health care fraud and 20 years in prison for each of three wire fraud counts. He also faces a two year mandatory minimum each for three aggravated identity theft counts.
James carried out an “audacious scheme”.
U.S. Attorney Breon Peace for the Eastern District of New York didn’t mince words when discussing James’ actions. “The defendant stands convicted of carrying out an audacious scheme in which he used insurance companies like ATM machines,” he is quoted as saying in the DoJ report, “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.”
Assistant Attorney General Kenneth A. Polite, Jr. of the Justice Department’s Criminal Division added the following: “James orchestrated a fraudulent medical billing scheme to steal from insurance companies and businesses, in order to line his own pockets. This conviction shows that medical billers who fuel health care fraud will be brought to justice.”
Are you an attorney working on a fraud case?
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