Manhattan U.S. Attorney Announces Indictment And Arrest Of Ophthalmologist For Healthcare Fraud
Government Also Files Civil Fraud Lawsuit Against Ophthalmologist and His Medical Practice
Geoffrey S. Berman, the United States Attorney for the Southern District of New York, William F. Sweeney Jr., Assistant Director-in-Charge of the New York Office of the Federal Bureau of Investigation (“FBI”), and Scott Lampert, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General’s (“HHS-OIG”) New York Region, announced today that AMEET GOYAL, M.D. (“GOYAL”), an ophthalmologist with practices in Rye, Mt. Kisco, and Wappingers Falls, New York, and Greenwich, Connecticut, has been indicted for healthcare fraud. Mr. Berman’s Office also today filed a civil fraud complaint against GOYAL and the entity that owns his medical practice, AMEET GOYAL, M.D, P.C. d/b/a/ THE EYE ASSOCIATES GROUP (the “Practice”), under the False Claims Act.
Specifically, the Indictment charges GOYAL with fraudulently billing patients, Medicare, and private insurance programs millions of dollars, between 2010 and 2017, for complex eye surgeries that GOYAL had not actually performed. The Civil Complaint further alleges that GOYAL and his Practice engaged in widespread healthcare fraud by consistently “upcoding” these and other surgical procedures, examinations, and tests in fraudulent billings submitted to Medicare and Medicaid. As alleged, GOYAL also falsified patient medical records, pressured other employees in his Practice to engage in the scheme, and initiated debt collection proceedings against patients who did not pay the full amounts of his fraudulently billed charges.
GOYAL was arrested this morning and was arraigned in federal court today before United States Magistrate Judge Paul E. Davison. The case is assigned to U.S. District Judge Cathy Seibel.
U.S. Attorney Geoffrey S. Berman said: “As alleged, Dr. Ameet Goyal repeatedly upcoded minor ophthalmological procedures, defrauding insurers and patients by grossly overbilling, netting millions in ill-gotten gains in the process. As further alleged, Goyal also billed for tests and procedures that were never performed, falsified medical records, bullied others in his practice to abet the scheme, and intimidated patients who questioned their bills. Thanks to our law enforcement partners, Goyal’s conduct has come into focus. Ameet Goyal now faces criminal prosecution and civil sanctions for his conduct.”
FBI Assistant Director William F. Sweeney Jr. said: “When we go to the doctor, we have to put our faith in their knowledge because they have expertise we don’t. Dr. Goyal allegedly lied to patients about what they were being billed for, forced them to pay for treatments they didn’t receive, and then threatened his staff if they expressed alarm about taking part in the fraud. Medical practitioners who are more concerned with their profits than with the health of their patients are going against the oath they took, they are doing harm and they should be held accountable.”
HHS-OIG Special Agent in Charge Scott Lampert said: “Goyal’s reprehensible conduct compromised patient care and undermined the integrity of the Medicare program. Along with our law enforcement partners, HHS-OIG will continue to protect the public and ensure that those who bill for services provided by taxpayer funded health care programs do so in an honest manner.”
According to the Indictment:
From at least in or about January 2010 through in or about March 2017, GOYAL systematically submitted false and fraudulent claims that misrepresented the services provided to patients of the Practice and falsely billed for higher-paying surgical treatments than the lower-paying, minor procedures actually performed.
For example, GOYAL and others at the Practice routinely treated patients for an excision of a chalazion, a small bump on an eyelid, typically removed in less than 15 minutes. An excision of chalazion, when billed truthfully under its associated code, paid the Practice 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 an orbitotomy together with a conjunctivoplasty, which are complex surgeries into the orbit of the eye, often to remove an orbital tumor, that typically take an hour or more to perform. These substantial surgeries, as billed, paid the Practice approximately $1,400 on average from a combination of insurance and patient out-of-pocket payments. Goyal also upcoded certain superficial procedures as an excision and repair of eyelid, a type of higher-paying eyelid surgery involving reconstruction or removal of certain lesions other than chalazions. During the relevant time period, GOYAL billed less than 40 chalazions under the billing code designated for excision of chalazion, while billing over 1,400 orbitotomies, over 700 bundled conjunctivoplasties, and over 1,600 excision and repair of eyelid surgeries, all of which he claimed to have performed personally.
To further effectuate the scheme, GOYAL directed other employees of the Practice, including other ophthalmologists, to upcode minor procedures into higher-paying surgeries. GOYAL threatened the livelihood of employees who were reluctant to comply with these directions.
Between about January 2010 through about March 2017, GOYAL caused the Practice to bill insurance programs and patients over $8 million for supposedly performed orbitotomies, bundled conjunctivoplasties, and excisions and repair of eyelid. The Practice received over $3 million in payments for these claims, a substantial portion of which were fraudulently billed.
According to the Civil Complaint, in addition to falsely billing for orbitotomies and conjunctivoplasties and other related codes:
GOYAL and his Practice routinely submitted fraudulent claims to Medicare and Medicaid for a wide range of other surgical procedures, examinations, and tests purportedly performed by GOYAL that were not actually performed, not medically necessary, not documented in the medical records, and/or failed to otherwise comply with Medicare and Medicaid rules and regulations. In order to justify this billing, GOYAL falsified patient diagnoses and prepared operative reports that falsely described the procedures performed on patients. The lawsuit seeks to recover treble damages and civil penalties under the False Claims Act.
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GOYAL, 56, of Rye, New York, is charged with three counts in the Indictment. The first count charges healthcare fraud, which carries a maximum sentence of 10 years in prison; the second count charges wire fraud, which carries a maximum sentence of 20 years in prison; the third count charges making false statements relating to health care matters, which carries a maximum sentence of five years in prison. The maximum potential sentences are prescribed by Congress and are provided here for informational purposes only, as any sentencing of the defendant will be determined by the judge.
Mr. Berman praised the outstanding investigative work of the FBI and HHS-OIG.
This criminal case is being handled by the Office’s White Plains Division. Assistant U.S. Attorneys Vladislav Vainberg, David Felton, and Margery Feinzig are in charge of the prosecution. The civil lawsuit is being handled by the Office’s Civil Frauds Unit. Assistant U.S. Attorney Jeffrey K. Powell is in charge of the civil case.
The charges contained in the Indictment are merely accusations, and the defendant is presumed innocent unless and until proven guilty.
 As the introductory phrase signifies, the entirety of the text of the Indictment, and the description of the Indictment set forth herein, constitute only allegations, and every fact described should be treated as an allegation.