November 25, 2024 | Santa Ana, CA — MedLegalNews.com — A convicted fraudster with a history of workers’ compensation crimes is at the center of a new workers’ comp fraud scheme involving nearly $100 million in fraudulent claims. Prosecutors say the elaborate operation reflects one of California’s largest alleged insurance fraud conspiracies to date, exposing how medical management networks and referral kickbacks can be exploited to manipulate the state’s workers’ compensation system.
Details of the Alleged Scheme
After a three-year investigation, the Orange County District Attorney’s Office announced on Friday that David Fish, 55, of Laguna Niguel, is accused of orchestrating a complex scheme to manage clinics and providers. Fish allegedly directed providers to refer patients to specific individuals in exchange for illegal referral fees, then fraudulently billed workers’ compensation insurance companies for the services.
Fish, along with San Diego neurosurgeon Dr. Vrijesh Tantuwaya, Martin Brill, 78, of Los Angeles, and Robert Lee, 61, of Rancho Mirage, allegedly formed Southern California Injured Workers (SCIW), a medical management company. Though listed as a consultant, prosecutors say Fish exerted complete control over SCIW’s operations.
Formation of Injured Workers Medical Group
The group also created Injured Workers Medical Group, with Dr. Tantuwaya designated as its CEO. The medical group became SCIW’s primary client, funneling patients into a network of providers to submit fraudulent claims. Prosecutors estimate the group billed nearly $100 million to workers’ compensation carriers during this period.
Charges and Potential Sentences
The defendants face 13 felony charges, including conspiracy to commit a crime, client referral for compensation, and insurance fraud. If convicted, Fish could serve up to 18 years and four months in prison. Brill and Lee face maximum sentences of 12 years and four months each, while Tantuwaya could receive up to 13 years.
The Broader Impact of Insurance Fraud
Orange County District Attorney Todd Spitzer condemned the scheme, emphasizing its effect on American families. “Criminals like these drive up insurance premiums, putting the American dream further out of reach for hardworking people,” Spitzer said.
Insurance fraud costs California approximately $17.2 billion annually, translating to an average financial burden of $440 per resident through higher premiums, taxes, and prices, according to the California Department of Insurance.
Defense Statements
Fish’s attorney, Benjamin N. Gluck, argued that the charges lack merit, stating, “The Orange County District Attorney’s Office has a history of filing similar cases only to have them collapse under scrutiny.” Dr. Tantuwaya’s attorney also maintained his client’s innocence, expressing confidence that the evidence would clear his name.
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FAQs: Understanding the Workers’ Comp Fraud Scheme Case
What is a workers’ comp fraud scheme?
A workers’ comp fraud scheme typically involves coordinated referral kickbacks, inflated billing, or false medical claims intended to deceive insurers or benefit providers—and that is exactly what prosecutors allege in this case.
Who is accused in this $100M workers’ comp fraud scheme?
The scheme centers on David Fish, alongside co-defendants including Dr. Vrijesh Tantuwaya, Martin Brill, and Robert Lee, who allegedly managed clinic referrals and billing networks to execute the fraud.
What charges are filed in this workers’ comp fraud scheme?
Authorities have brought 13 felony counts, including conspiracy, illegal referral for compensation, false or fraudulent claims, and insurance fraud, tied to the orchestrated scheme.
What potential penalties could result from this workers’ comp fraud scheme?
If convicted, David Fish could face up to 18 years and four months in prison, while the other defendants face terms ranging from 12 to 13+ years each.