This case involves the owner of a medical care facility who was suspected of committing vendor medical provider fraud for services not rendered. This was related to a workers’ compensation claim involving a claimant who was in need of medical care and services for his injury. The claimant was injured in 1996 when he was employed in the capacity of a volunteer firefighter when he fell, hitting his head, which lead to an anoxic brain injury. He was later diagnosed with Wolff-Parkinson-White syndrome where he would need daily assistance and care of an aide.

In 2020, during the claims process, the claimant had been receiving care and services from an aide of this particular medical care facility. The claimant’s father indicated the last time that the medical aide had provided assistance and care to the claimant had been sometime in March of 2020. This is when the aide of the medical care facility began to not show up to provide assistance and care to the claimant. The claimant’s father did not think much of the aide not showing up because this had also been during the time of the COVID-19 pandemic. From March of 2020 to December of 2020, the insurance company paid the owner of the medical care facility for services related to the claimant in the approximate amount of $79,200.00.

In 2021, the owner of the medical care facility had been contacted by the defense attorney who represented the insurance company. The owner stated he would pay back the amount in full once he secured a loan. However, he failed to reimburse the fraudulent payments that he received.

On September 17, 2021, a fraud referral was submitted to the Sonoma County District Attorney’s Office. On November 19, 2021, the Sonoma County District Attorney’s Office opened a criminal investigation as a result of the fraud referral. Subsequently, a Documented Fraud Referral and a copy of the claim file was provided to the Sonoma County District Attorney’s Office as a result of the 1877 Demand Letter. Throughout the duration of the investigation, Apex SIU investigators worked closely with the Sonoma County District Attorney’s Office investigators and provided additional information to assist with their investigation.

In March of 2022, the Sonoma County District Attorney’s Office filed (3) felony counts of workers’ compensation fraud against the owner of the medical care facility. On May 6, 2024, he took a plea, which consisted of the following:

• (1) felony count of workers’ compensation fraud.
• Restitution imposed in the amount of $73,300.00.
• Two years of formal probation.
• Complete 60 hours of community service.