NEW YORK – A medical biller has been sentenced to 12 years in federal prison for orchestrating a massive insurance fraud scheme, prosecutors announced. Matthew James, 54, was found guilty of impersonating an NBA player and other patients to fraudulently claim payments from insurance companies.
U.S. District Judge Joanna Seybert condemned James’s actions as “inexcusable” during the sentencing in Central Islip, according to Newsday. “Ruining people’s reputations, doing all of that for money, is realy breathtaking,” Seybert stated.
Medical Biller Sentenced for Multimillion-Dollar Insurance Fraud
James was convicted in July 2022 on fraud and identity theft charges. Prosecutors detailed that he defrauded multiple insurers out of hundreds of millions of dollars through his medical billing companies.
Scheme Involved Falsifying Procedures and Impersonating Patients
The scheme involved scheduling elective surgeries in emergency rooms to inflate insurance reimbursement rates and billing for procedures that were never performed.
James also impersonated patients and insured individuals when insurers denied claims, demanding payments while posing as an outraged party facing exorbitant bills.
NBA Player Marcus Smart Among Those Impersonated
Among those James impersonated was NBA player Marcus Smart, then with the Boston Celtics. Smart had undergone hand surgery in 2018 after hitting a stanchion, according to court documents.
Smart testified that the impersonation bothered him and expressed concern that it could damage his reputation as a role model, according to court documents. at the time of the trial, Smart had won the NBA Defensive Player of the Year award in 2022. He now plays for the Memphis Grizzlies.
**How does this case of insurance fraud impact patient trust in the healthcare system and what steps can the PAA take too address this erosion of trust?**
Q&A: Medical Biller’s Multimillion-Dollar Insurance Fraud Scheme
Dive deeper into the shocking case of Matthew James, the medical biller sentenced to 12 years for orchestrating a massive insurance fraud scheme. Here’s a breakdown of the key questions and details:
What was Matthew James’s fraud scheme?
James defrauded multiple insurance companies out of hundreds of millions of dollars. His scheme involved:
- Scheduling elective surgeries in emergency rooms to inflate reimbursement rates.
- Billing for procedures that were never performed.
- Impersonating patients and insured individuals to demand payments when claims were denied.
Who was impersonated in the scheme?
One of the most notable victims of James’s impersonations was NBA player marcus smart, then with the Boston Celtics. James’s actions raised concerns about the potential damage to Smart’s reputation.
What were the charges and penalties?
James was convicted in July 2022 on fraud and identity theft charges. He was sentenced to 12 years in federal prison, a sentence U.S. District Judge Joanna Seybert called “inexcusable.”
What is the purpose behind insurance fraud prevention?
the purpose of insurance fraud prevention is to help ensure that the business of insurance involves many transactions that are honest. The Insurance Fraud Prevention Model Act outlines the creation and purpose of an insurance fraud unit, insurer antifraud initiatives, regulations, and penalties, to prevent fraudulent activities. [[1](https://content.naic.org/sites/default/files/model-law-680.pdf)]
Why are emergency rooms used for elective surgeries in these types of scams?
Elective surgeries in emergency rooms allow for inflated insurance reimbursement rates,thereby increasing the fraud’s financial gain.
Interesting Trivia: Insurance fraud is a important problem, costing the U.S. billions of dollars annually. This case highlights the lengths fraudsters will go to and the devastating impact on individuals and the healthcare system.
This case serves as a stark reminder of the importance of vigilance and ethical behavior within the healthcare and insurance industries. Stay informed and report any suspicious activity.
