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,” Peace said. “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.”
James operated medical billing companies to provide billing services for physicians, primarily plastic surgeons throughout the United States. 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.
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, prosecutors said.