CEO impersonated patients, convicted in $600M surgical billing fraud

Mathew James, CEO of medical billing company Leal, was convicted over a $600 million fraud and identity theft scheme, the Justice Department said July 13.

Through his company, Mr. James, 54, billed payers for surgeries with higher reimbursement rates than the procedures his physician-clients actually performed, the department said. He also directed physicians to schedule elective surgeries through the emergency room so payers would give much bigger reimbursements.

If a payer denied one of the inflated claims, Mr. James would impersonate the patient and demand the payer cover the outstanding balance of tens or hundreds of thousands of dollars, the department said.

When sentenced, Mr. James faces up to 10 years in prison for each of two healthcare fraud counts, up to 20 years for each of three wire fraud counts, and a mandatory minimum of two years apiece for each of three identity theft counts, the department said.

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