Man charged in $100 million workers’ comp fraud scheme

A man previously convicted of workers’ compensation fraud has been charged for the third time in connection with an alleged $100 million scheme involving a neurosurgeon and two others, according to the Orange County District Attorney’s Office.

According to AM Best, the four defendants face 13 felony charges, including conspiracy to commit a crime, referral of clients for compensation, and submitting false and fraudulent claims, as outlined by the district attorney.

David Fish, one of the defendants, is accused of controlling clinics and healthcare providers who would see patients and then refer them to certain providers in exchange for illegal referral payments. These services were billed to workers’ compensation carriers, according to the District Attorney’s Office.

Fish has previously been convicted twice for workers’ compensation fraud and is permanently banned from participating in California’s workers’ compensation system, the office said.

Fish allegedly worked with Martin Brill and Robert Lee to create Southern California Injured Workers (SCIW), a company that provided medical management services, including marketing, billing, and collections.

While Fish was listed as a consultant for the company, the district attorney claims he had complete control over its operations.

The group also partnered with San Diego neurosurgeon Vrijesh Tantuwaya to form a medical group named Injured Workers Medical Group, which became SCIW’s primary client. Tantuwaya was listed as the owner and CEO of the group, according to the district attorney.

The group operated the scheme for three years, directing patient referrals to a limited group of clinics, submitting claims nearing $100 million, and receiving illegal referral fees, the District Attorney’s Office said.

Orange County District Attorney Todd Spitzer (pictured above) addressed the broader impact of insurance fraud, noting that schemes like this drive up costs for American families.

Spitzer said that while people are facing increasing expenses, “criminals like these only increase the cost of insurance premiums and put the American dream further out of reach for many hardworking people.”

If convicted, Fish could face up to 18 years and four months in prison. Brill and Lee could each face a maximum sentence of 12 years and four months, while Tantuwaya could receive a sentence of up to 13 years.

Insurance fraud in California costs approximately $17.2 billion annually, according to the California Department of Insurance, with the financial impact resulting in an average cost of $440 per resident due to higher premiums, taxes, and prices.

What are your thoughts on this story? Please feel free to share your comments below.