Prosecutors Say New York Insurer Falsely Billed for Brain Surgeries

Four New Yorkers defrauded a health insurance company by making false claims for brain operations, sometimes for the same person on multiple occasions, authorities said.

One 36-year-old Manhattan man even claimed nine brain surgeries for himself, along with his wife and two sons, receiving reimbursements from New York-based Group Health Incorporated totaling $142,268, federal investigators said.

In all, the defendants billed the company for 20 brain operations – though none were ever performed, investigators said. GHI paid out more than $300,000 in reimbursements, based on the claims.

The 36-year-old man remained at large last week, but his co-defendants, a 39-year-old Mount Vernon man, a 42-year-old Manhattan woman and a 37-year-old Staten Island man were in custody.

The indictment filed in Manhattan federal court alleges that the Mount Vernon man, an employee at a medical billing company, altered claims to the insurance company by swapping the names of people who actually underwent brain surgery with two others charged in the scheme – the 36-year-old man and the 42-year-old woman.

The fraudulent claims were then sent along with altered postoperative reports to the insurance carrier to obtain reimbursement, the indictment alleges.

Ilene Margolin, a spokeswoman for GHI, told The New York Times that her company’s own internal investigators first noticed the defendants’ unusual claims before turning over its findings to the government.