Post 4851<\/span><\/strong><\/h3>\nFraud to Private and Public Health Insurers Doesn\u2019t Pay![\"\"](\"https:\/\/i0.wp.com\/zalma.com\/blog\/wp-content\/uploads\/2026\/09\/Psychiatrist-fraud.png?resize=640%2C360\")
<\/span><\/strong><\/h3>\nIn United States v. Gustavo Kinrys,<\/em> Nos. 24-1592, 24-1716, United States Court of Appeals, First Circuit (September 21, 2026) Gustavo Kinrys, a Massachusetts psychiatrist, submitted fraudulent claims to private and public health insurers from 2015 through 2018, including bills for more than 1,000 sessions when he or the purported patient was outside the country. When insurers requested supporting records, he delayed through a fictitious office manager and created false documentation.<\/p>\nA jury convicted Kinrys on fourteen counts. The district court imposed a 99-month sentence, calculated intended loss at slightly more than $19 million based on billed amounts, ordered $6,537,309.59 in restitution, and ordered $6,527,391.19 in forfeiture.<\/p>\n
At sentencing, the district court calculated Kinrys\u2019s base offense level to be seven and then added twenty-eight levels-worth of enhancements, including a twenty-level enhancement for the loss amount. This yielded a recommended guideline range of 168 to 210 months for the first seven counts of conviction, and sixty months for the remaining counts. The district court sentenced Kinrys to ninety-nine months in prison on the first seven counts and sixty concurrent months in prison on the remaining counts. It also required Kinrys to pay $6,537,309.59 in restitution and $6,527,391.19 in criminal forfeiture.<\/p>\n
LAW:<\/span><\/h2>\nUnder U.S.S.G. \u00a7 2B1.1(b)(1), loss is the greater of actual or intended loss. When a scheme is rife with fraud, the billed amount is prima facie evidence of intended loss; the defendant may rebut it with evidence that he intended to obtain less, but the government retains the ultimate burden to prove the enhancement by a preponderance of the evidence. Subjective intent is reviewed for clear error.<\/p>\n
Under the Mandatory Victims Restitution Act, restitution compensates victims for actual losses caused by fraud and may not produce a windfall; distinct civil claims against victims are not adjudicated at a criminal restitution hearing.<\/p>\n
DISCUSSION:<\/span><\/strong><\/h2>\nKinrys argued that intended loss should equal the roughly $8.3 million he expected under negotiated in-network reimbursement rates rather than the more than $19 million billed, reducing the enhancement from twenty to eighteen levels. He relied on his provider contracts and failure to collect co-pays. He also argued that restitution should be reduced by allegedly legitimate claims for which insurers had not paid him.<\/p>\n
ANALYSIS:<\/span><\/strong><\/h2>\nThe First Circuit held that the district court did not clearly err in using billed amounts. Although Kinrys\u2019s in-network status supported his position, other evidence supported an intent to obtain as much as possible: he sued insurers for billed charges and greater damages, sometimes received full billed amounts, retained payments exceeding contract rates, and offered no contrary evidence at sentencing beyond counsel\u2019s argument.<\/p>\n
His failure to collect co-pays was not persuasive because collection could have exposed the scheme or discouraged patients. The restitution offset also failed because the order included only fraudulent claims, while the unpaid claims were separate, disputed reimbursement requests affected by unmet preauthorization or documentation requirements. Any entitlement to those payments belonged in a civil or administrative proceeding, not the restitution hearing.<\/p>\n
CONCLUSION:<\/span><\/strong><\/h2>\nThe First Circuit affirmed both the intended-loss calculation and the restitution order.<\/p>\n
A criminal restitution hearing, where distinct, unrelated, and contested billing is not before the court, is not the proper venue to resolve such claims. Accordingly, the First Circuit affirmed the district court\u2019s decision to decline offsetting the restitution order based on Kinrys\u2019s allegedly legitimate claims.<\/p>\n
Psychiatrist convicted of insurance fraud and ordered to make restitution tried to reduce the order or eliminate it unsuccessfully to the First Circuit Court of Appeal. His crime was obvious, the amount he obtained from defrauded insurers and the government was proved by the DOJ and the trial court\u2019s decision was affirmed.<\/p>\n
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<\/p>\n
(c) 2026 Barry Zalma & ClaimSchool, Inc.<\/p>\n
Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos.<\/p>\n
Subscribe to my substack at https:\/\/barryzalma.substack.com\/subscribe<\/a><\/p>\nGo to X @bzalma;\u00a0 Go to Barry Zalma videos at Rumble.com at https:\/\/rumble.com\/account\/content?type=all;<\/a> Go to Barry Zalma on YouTube- https:\/\/www.youtube.com\/channel\/UCysiZklEtxZsSF9DfC0Expg; Go to the Insurance Claims Library \u2013 <\/a>https:\/\/lnkd.in\/gwEYk.\u00a0<\/a><\/p>\nRelated<\/em><\/h3>\n<\/p><\/div>\n
<\/span><\/strong><\/h3>\nIn United States v. Gustavo Kinrys,<\/em> Nos. 24-1592, 24-1716, United States Court of Appeals, First Circuit (September 21, 2026) Gustavo Kinrys, a Massachusetts psychiatrist, submitted fraudulent claims to private and public health insurers from 2015 through 2018, including bills for more than 1,000 sessions when he or the purported patient was outside the country. When insurers requested supporting records, he delayed through a fictitious office manager and created false documentation.<\/p>\n A jury convicted Kinrys on fourteen counts. The district court imposed a 99-month sentence, calculated intended loss at slightly more than $19 million based on billed amounts, ordered $6,537,309.59 in restitution, and ordered $6,527,391.19 in forfeiture.<\/p>\n At sentencing, the district court calculated Kinrys\u2019s base offense level to be seven and then added twenty-eight levels-worth of enhancements, including a twenty-level enhancement for the loss amount. This yielded a recommended guideline range of 168 to 210 months for the first seven counts of conviction, and sixty months for the remaining counts. The district court sentenced Kinrys to ninety-nine months in prison on the first seven counts and sixty concurrent months in prison on the remaining counts. It also required Kinrys to pay $6,537,309.59 in restitution and $6,527,391.19 in criminal forfeiture.<\/p>\n Under U.S.S.G. \u00a7 2B1.1(b)(1), loss is the greater of actual or intended loss. When a scheme is rife with fraud, the billed amount is prima facie evidence of intended loss; the defendant may rebut it with evidence that he intended to obtain less, but the government retains the ultimate burden to prove the enhancement by a preponderance of the evidence. Subjective intent is reviewed for clear error.<\/p>\n Under the Mandatory Victims Restitution Act, restitution compensates victims for actual losses caused by fraud and may not produce a windfall; distinct civil claims against victims are not adjudicated at a criminal restitution hearing.<\/p>\n Kinrys argued that intended loss should equal the roughly $8.3 million he expected under negotiated in-network reimbursement rates rather than the more than $19 million billed, reducing the enhancement from twenty to eighteen levels. He relied on his provider contracts and failure to collect co-pays. He also argued that restitution should be reduced by allegedly legitimate claims for which insurers had not paid him.<\/p>\n The First Circuit held that the district court did not clearly err in using billed amounts. Although Kinrys\u2019s in-network status supported his position, other evidence supported an intent to obtain as much as possible: he sued insurers for billed charges and greater damages, sometimes received full billed amounts, retained payments exceeding contract rates, and offered no contrary evidence at sentencing beyond counsel\u2019s argument.<\/p>\n His failure to collect co-pays was not persuasive because collection could have exposed the scheme or discouraged patients. The restitution offset also failed because the order included only fraudulent claims, while the unpaid claims were separate, disputed reimbursement requests affected by unmet preauthorization or documentation requirements. Any entitlement to those payments belonged in a civil or administrative proceeding, not the restitution hearing.<\/p>\n The First Circuit affirmed both the intended-loss calculation and the restitution order.<\/p>\n A criminal restitution hearing, where distinct, unrelated, and contested billing is not before the court, is not the proper venue to resolve such claims. Accordingly, the First Circuit affirmed the district court\u2019s decision to decline offsetting the restitution order based on Kinrys\u2019s allegedly legitimate claims.<\/p>\n Psychiatrist convicted of insurance fraud and ordered to make restitution tried to reduce the order or eliminate it unsuccessfully to the First Circuit Court of Appeal. His crime was obvious, the amount he obtained from defrauded insurers and the government was proved by the DOJ and the trial court\u2019s decision was affirmed.<\/p>\n (c) 2026 Barry Zalma & ClaimSchool, Inc.<\/p>\n Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos.<\/p>\n Subscribe to my substack at https:\/\/barryzalma.substack.com\/subscribe<\/a><\/p>\n Go to X @bzalma;\u00a0 Go to Barry Zalma videos at Rumble.com at https:\/\/rumble.com\/account\/content?type=all;<\/a> Go to Barry Zalma on YouTube- https:\/\/www.youtube.com\/channel\/UCysiZklEtxZsSF9DfC0Expg; Go to the Insurance Claims Library \u2013 <\/a>https:\/\/lnkd.in\/gwEYk.\u00a0<\/a><\/p>\nLAW:<\/span><\/h2>\n
DISCUSSION:<\/span><\/strong><\/h2>\n
ANALYSIS:<\/span><\/strong><\/h2>\n
CONCLUSION:<\/span><\/strong><\/h2>\n
<\/p>\nRelated<\/em><\/h3>\n<\/p><\/div>\n