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How a Need for Profit Led Health Care Providers to Crime
Post 5185

This is a Fictionalized True Crime Story of Insurance Fraud from an Expert who explains why Insurance Fraud is a “Heads I Win, Tails You Lose” situation for Insurers. The story is designed to help to Understand How Insurance Fraud in America is Costing Everyone who Buys Insurance Thousands of Dollars Every year and Why Insurance Fraud is Safer and More Profitable for the Perpetrators than any Other Crime.

How Elderly Doctors Fund their Retirement

A dishonest physician or chiropractor will, for a fee, prepare fictitious medical reports, including billings for multiple series of physical therapy treatments. Sometimes the report of a legitimate accident victim is modified only in the name, address, and physical attributes of the victim. In all other respects, the reports are legitimate. They are not a report of the victim’s actual injuries since the victim either did not exist or was not injured. Medical bills generated by such fiction are never extensive and will total between $1200 and $3500. The numbers are kept small to avoid suspicion and tempt insurers into making a quick settlement.

When I was a young adjuster I dealt with these scofflaws and paid fraudulent claims because I, like most young adjusters, was unaware of the amount of fraud being perpetrated. Within a year I learned and refused to pay the suspected frauds and advised them that the insurer I worked for would pay nothing and they should file suit. I was convinced it was a fraud when the suit was never filed.

Because of the ease of use a single clerk typist with a word processor can prepare two hundred medical reports a day with the doctors’ laser printer even generating his signature from a scanned image. The doctor, not involved in the procedure, receives $100 to $500 per report. The doctor is quite happy with his earnings since he need not see a patient nor provide treatment.

This type of fraud operation can present hundreds of claims a month on individuals who were not injured or never injured. The claims can generate millions of dollars a year in net profits for the lawyers, physicians and recruiters involved in the crime. Insurance criminals discovered that the person claimed injured, (that is the lawyer’s alleged client) will almost never be seen by an adjuster, investigator or independent medical examiner.

The criminals know that as long as they keep the claims small no lawyer will be called upon to take testimony from the person identified as injured. The criminals know that no one will go to the medical clinic to learn whether they really provided the treatment claimed. Since the insurance criminals keep their medical treatment down to minimal level and the demands of the lawyer are always reasonable, the claims settle quickly. The adjuster’s supervisors commend the adjuster for closing files. The adjuster is rewarded for keeping expense costs down. The insurer saved the cost of a lawyer. The fraud was a success.

Occasionally, we read reports about the US DOJ, police or the fraud bureaus making arrests of a massive fraud ring. The arrests just touch the cream at the top of the glass of milk. The rest remains. It is greed that causes the criminal’s demands to become sufficiently high to cause the insurer to investigate the claim.

Insurers must realize that savings of expense dollars can, and almost always will, cost them more in indemnity dollars.

Data base systems allow insurers to obtain records concerning all claims supported by the crooked chiropractor, lawyer or physician. If volume is too high the information provided to an insurer from the All Claims Database, CLUE, or other databases will raise suspicions of fraud sufficient to compel a thorough fraud investigation.

A Modern Example of Health Insurance Fraud
37 Months in Prison

Niranjan Mittal, a Brooklyn-based cardiologist, was sentenced in 2025 to 37 months in prison for his participation in a years-long healthcare fraud and bribery scheme that involved paying other physicians for referrals and fabricating patient records. The 72-year-old was also sentenced to two years of supervised release and forced to forfeit all proceeds that can be traced to this scheme.

Mittal was arrested for his role in this scheme back in 2023. At the time, he was charged with one count of conspiracy to commit healthcare fraud and wire fraud, one count of healthcare fraud, one count of conspiracy to violate the Anti-Kickback Statute, and one count of violating the Anti-Kickback Statute. He would go on to plead guilty to the one count of violating the Anti-Kickback Statue in February 2025.

According to various court documents and statements made during court proceedings, Mittal operated a medical clinic that primary served patients who were insured by government healthcare programs. He would pay rental payments to other providers that were actually just payments for patient referrals. In addition, his staff members were encouraged to go to the offices of other providers, perform “basic tests” on patients and then convince those same patients that they needed follow-up care at Mittal’s own clinic. Those patients would then arrive with no idea why they were being referred for follow-up care—and the real reason was, Mittal wanted the required documentation to support treating those patients with vascular interventional procedures they did not need.

If necessary, Mittal would also dictate others to lie about the symptoms of these patients in their medical records, all so they would be seen as medically appropriate candidates for these unnecessary procedures.

According to the DOJ, this scheme resulted in some patients undergoing 10 or more interventional procedures they did not need. And from 2016 to 2023, insurance companies paid more than $40 million to Mittal’s practice for these false and fraudulent claims.

Adapted from my book Insurance Fraud Costs Everyone Available as a Kindle Book and Available as a Paperback from Amazon.com.

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