Ophthalmologist eyes prison term for seven-year scam

He stole $3.6 million from insurers and patients, says Justice Department

Ophthalmologist eyes prison term for seven-year scam

Insurance News

By Ryan Smith

A New York ophthalmologist has been sentenced to 96 months in prison for masterminding a seven-year insurance fraud scheme.

Ameet Goyal, of Rye, N.Y., falsely billed for millions of dollars of upcoded procedures, according to Damian Williams, US attorney for the Southern District of New York. Goyal also fraudulently obtained two government-guaranteed loans intended to help small businesses during the COVID-19 pandemic while he was on pretrial release for the healthcare scam. Goyal pleaded guilty in September to all six charges against him.

In addition to the prison term, Goyal was sentenced to five years of supervised release and ordered to pay a forfeiture of $3.6 million and another $3.6 million in restitution. He has already paid approximately $1.79 million toward these obligations, according to the Department of Justice.

“A prominent ophthalmologist and oculoplastic surgeon who has now surrendered his medical license, Ameet Goyal was blinded by greed,” Williams said. “Over a seven-year period, he preyed on the trust placed in him and cheated patients and insurance companies of $3.6 million in false charges. To cover his tracks, he created fictitious operative reports, seeded across hundreds of patient files, violating the integrity of the patients’ medical records and making it more difficult for subsequent doctors to evaluate their care.

“He sent patients who could not pay the upcoded bills to collection agencies, decimating their credit. He pressured other doctors to join the scheme and threatened to retaliate against their livelihoods and careers. Even after being arrested for this scheme, Goyal committed a breathtaking new fraud and stole $637,200 from the Paycheck Protection Program in the early days of a devastating pandemic. For his crimes, Goyal will serve a substantial sentence in prison.”

Goyal owned and operated the ophthalmology practice Ameet Goyal M.D. P.C., doing business as Rye Eye Associates, with three offices in New York state and one in Connecticut. Between 2010 and 2017, he consistently “upcoded” simpler, lower-paying surgical procedures as complex, higher-paying major operations.

He then submitted fraudulent bills for the upcoded procedures to patients, Medicare and private insurance companies. As a result, he was paid at least $3.6 million for procedures he didn’t perform. Goyal also failed to obtain proper – or, at times, any – consent for the procedures he claimed to have performed.

As part of the scam, Goyal also falsified medical records, writing phony operative reports to match the complex procedures he claimed to have performed, rather than the minor procedures he actually performed. He also pressured employees at his practice to participate in the scam, and threatened the livelihoods of employees who refused.

Goyal caused patients to pay thousands of dollars out of pocket for procedures he never performed, and initiated debt collection proceedings against patients who didn’t pay the full amount of the fraudulent charges. As a result of the scam, Goyal was the highest-billing doctor in the tri-state area for several of his fraudulently billed codes – one of which he billed seven times more frequently than all other doctors in the area combined. Goyal was indicted on healthcare fraud charges in 2019 and released on bail.

Around April 2020, while on bail, Goyal applied for $630,000 in government-guaranteed loans through the Paycheck Protection Plan, a government program initiated to help small businesses during the COVID-19 pandemic.

Specifically, Goyal first applied for a loan of $358,700 for the business “Ameet Goyal,” using his own Social Security number and email address. A few days later, he applied for a second loan in the amount of $278,500 using the business name “Rye Eye Associates” and the Employee Identification Number for Ameet Goyal M.D. P.C. and a different email address. He submitted the same underlying payroll expense report for each loan.

On both applications, Goyal falsely said that he was not facing any pending criminal charges. He also falsely claimed that his business would not receive another PPP loan until the end of the year. Once he received the funds from these loans, Goyal used the proceeds to pay both business and personal expenses, including making a payment to a country club in Westchester, N.Y., and payments to a California vineyard and a golf merchandise website.

“Fraud doesn’t fully capture how blatant this was and how unjustified this was,” US District Judge Cathy Seibel said while imposing the sentence. “...This was not about need, it was about greed.”

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