Jury Convicts NY Man in $600 Million Claims Billing, ID Theft Case

Sarasota, FL (WorkersCompensation.com) – A Long Island man has been convicted by federal jury of healthcare fraud, wire fraud, and identity theft to the tune of over $600 million in a case that involved not only the state’s Department Of Justice, but the FBI.

Aged 54, Matthew James owned and operated Leale Entities, starting in 2006. Leale Entities included Leale Billing Corp., Remm Consultants, and Elite Industrial. While Leale Billing was a medical billing company, Elite Industrial was also a billing company providing “scientific/professional and technical services”.

The complaint asserted that James upcoded and in some completely changed the services that were billed through his companies. Additionally, investigators stated that James misrepresented claims as more serious, complicated, or emergent than they actually were. An example given in the complaint was repeated claims for complex wound cleaning and closure, such as a debridement, when the actual procedure performed was merely stitches. Additionally, James directed the physicians that used his billing services to schedule elective surgeries in the emergency room for higher reimbursement of which he received a portion. Insurance companies identified in the complaint included Aetna, Cigna, United Healthcare, and Optum, however this was just a portion of insurance companies impacted.

In addition to the fraudulent billing, investigators state that upon denial of claims James would impersonate the patients in an attempt to coerce and in some cases bully the insurance to pay the claims. According to the complaint filed on June 10^th, James used “abusive language” in some of these impersonation calls that were recorded. Overall, investigators stated that they had identified over 150 impersonation calls in which he pretended to be 20 separate patients, resulting in over $12 million in payments from insurance.

In one call, James impersonated Jeff Pash, the National Football League’s general counsel. In yet another call, James impersonated Marcus Smart who is a well-known professional basketball player for the Boston Celtics.

The jury found James guilty on conspiracy to commit health care fraud, health care fraud, three counts of wire fraud, and three counts of aggravated identity theft. James could face up to 10 years each of prison time for healthcare fraud and conspiracy to commit healthcare fraud. For three counts of wire fraud, he could be looking at 20 years. James could be face a two-year mandatory minimum each for three aggravated identity theft counts.

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