Seeing Fraud for What It Is

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Medicare enrollment form and glasses

An ophthalmologist from Rye, N.Y., has pleaded guilty to perpetrating a seven-year healthcare fraud scheme. Ameet Goyal admitted to falsely billing for millions of dollars in procedures he did not perform and to fraudulently obtaining two Government-guaranteed loans intended to help small businesses during the COVID-19 pandemic. (This man certainly didn’t waste any time defrauding.)

Goyal owned and operated the ophthalmology practice, Ameet Goyal M.D. P.C., doing business as Rye Eye Associates. The practice had offices in Rye, Mt. Kisco, and Wappingers Falls, and, Greenwich, Conn. Between 2010 and 2017, Goyal engaged in widespread healthcare fraud by participating in a billing scheme that defrauded Medicare, private insurance companies, and patients. (Maybe Goyal needed his eyes checked since he couldn’t see the prison light at the end of the tunnel.)

Rye Eye Associates participated in a scheme known as “upcoding” in which lower-paying surgical procedures and examinations were billed as more complex, higher-paying operations. As a result, Goyal fraudulently obtained at least $3.6 million in payments for procedures he did not perform.

One of the routine operations Goyal and his employees conducted was an excision of a chalazion, a small bump on an eyelid, typically removed in less than 15 minutes.  An excision of this type, when billed under its associated code, resulted in Rye Eye being paid approximately $200 on average from patients and insurance programs.

However, Goyal systematically billed an excision of chalazion, and other similar superficial eyelid procedures, as if he had performed a complex surgery that took an hour or more to perform. (Like when your coworker claims that a one page report took them five hours.) To corroborate this scheme, Goyal forged operative reports that matched the complex operation he billed rather than the different minor procedure he actually performed.

Goyal also pressured his employees to engage in the scheme, threatening the livelihood of those who refused to comply. These false billings resulted in patients paying thousands of dollars of out-of-pocket costs for minor procedures. Goyal went so far as to initiate debt collection proceedings against patients who did not pay the full amounts of those false charges. (Did he not realize the irony in exploring legal action against individuals being schemed because of his illegal actions?)

During the time of this scheme, Goyal billed for complex surgeries including more than 1,400 orbitotomies, 700 bundled conjunctivoplasties, and 1,600 excision and repair of eyelid surgeries. (Goyal must secretly be superman because he claimed to have personally performed each, and every one of these surgeries.) As a result of this scheme, Goyal received more than $3.6 million in payments.

Additionally, while already facing these healthcare charges, Goyal committed a new fraud when applying for Paycheck Protection Program loans. Around April 2020, Goyal applied to the SBA and Bank-1, a federally insured institution, for over $630,000 in Government-guaranteed loans through the SBA’s PPP Program.

He applied for a loan in the amount of $358,700 for the business “Ameet Goyal,” with his own social security number and email address. Shortly after, he applied for a second loan in the amount of $278,500, with a business name “Rye Eye Associates,” using the Employer Identification Number for Ameet Goyal M.D. P.C and a different email address controlled by Goyal. 

To substantiate each loan, Goyal submitted the same underlying payroll expense report, showing the same employees and payroll costs. On both applications, Goyal falsely answered that he was not facing any pending criminal charges.

On May 4, 2020, Goyal received the first loan of $358,700, and on May 11, 2021, he received the second loan of $278,500. He used this money to pay business and personal expenses. (This includes his local country club membership.)

In total, Goyal obtained over $630,000 in federal funds earmarked for legitimate small businesses affected by the COVID-19 pandemic.  Goyal admitted to both the fraudulent healthcare and COVID schemes, agreed to forfeit $3.6 million, and faces the possibility of a significant term of incarceration. Goyal is now scheduled to be sentenced on January 6, 2022. (Rest-eye-sured Goyal will have to pay for his crimes.)

Today’s Fraud of the Day comes from a Department of Justice press release, “Ophthalmologist Pleads Guilty To Seven-Year Healthcare Fraud Scheme And To Defrauding SBA Program Intended To Help Small Businesses During COVID-19 Pandemic,” published on September 14, 2021.

Audrey Strauss, the United States Attorney for the Southern District of New York, announced that AMEET GOYAL, an ophthalmologist in Rye, New York, pled guilty yesterday to perpetrating a seven-year healthcare fraud scheme by falsely billing for millions of dollars of procedures he did not perform, and also to fraudulently obtaining two Government-guaranteed loans intended to help small businesses during the COVID-19 pandemic while facing charges on pretrial release for the healthcare fraud scheme.  GOYAL pled guilty before U.S. District Judge Cathy Seibel to all charges in a six-count superseding Indictment.

U.S. Attorney Audrey Strauss said: “Dr. Ameet Goyal was an experienced eye doctor who became blinded by greed and routinely defrauded patients who trusted him to heal their eyes.  He grossly overbilled minor ophthalmological procedures, billed for tests and procedures that were never performed, falsified medical records, attempted to corrupt others in his practice to abet the scheme, and sent patients who refused to pay his fraudulent charges to collections.  Already facing charges for defrauding patients and insurers of millions of dollars, Goyal committed a new fraud in applying for Paycheck Protection Program loans on behalf of two separate businesses and lying on the applications.  Goyal looted over $630,000 in federal funds earmarked for legitimate small businesses affected by the COVID-19 pandemic.  Goyal has now admitted to both fraudulent schemes, agreed to forfeit $3.6 million, and faces the possibility of a significant term of incarceration.”

 

 

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.