Fraud Could Mean Hefty Fines, Loss of License

Insurance fraud is a crime, and Delta Dental is committed to stopping it. We are required by law to report any reasonable suspicion of fraud to the Office of the Insurance Fraud Prosecutor (OIFP). Failing to do so could result in penalties of up to $25,000 per violation.

Dentists found guilty of fraud face possible fines, attorney fees, the loss of their professional licenses, and jail time. Patients, office staff, employer groups, and brokers also face punishment if they are knowingly involved in acts of fraud.

Recently, a dentist whom we referred to the OIFP admitted to one act of insurance fraud and agreed to pay $100,000 in penalties and attorney fees. The patient's maximum benefits had been expended for the year, so the dentist misrepresented the patient's date of treatment on the claim form. This caused the claim to be incorrectly processed under the patient's benefits for the following year.

Consent orders can be filed years after an insurance carrier concludes its investigation. Eight years after one of our cases concluded (with Delta Dental recovering more than $150,000), the New Jersey State Board of Dentistry imposed an additional $25,000 in civil penalties and cots, plus a license suspension.

Since 2003, 20 consent orders were filed in matters where Delta Dental had made a referral to the OIFP. These resulted in:

• Criminal penalties and fines: $30,550

• Civil fraud penalties: $372,500

• Restitution and fines: $439,359

• Costs and attorney fees: $59,000

• Prison time: More than three years

• Probation: 11 years

• License suspensions: Nine (including five permanently losing their licenses)

• Community service: 100 hours

Dentists found guilty of fraud may also face ongoing random audits and be required to take dental and business courses.

You should be aware that the consent orders and criminal proceedings are matters of public record. Insurance fraud can not only cost you money, but it can destroy your practice and your reputation.

For more information, please refer to:

• New Jersey State Board of Dentistry, Administrative Code [NJAC 13:30-8.10], at www.state.nj.us/lps/ca/medical/dentistry.htm

• The New Jersey Health Care Fraud Claims Act [N.J.S.A. 2C: 21 4.2-3], at www.nj-statute-info.com/getStatute.php?statute_id=1634, and www.nj-statute-info.com/getStatute.php?statute_id=1635

• The New Jersey Insurance Fraud Prevention Act, [N.J.S.A. 17:33A 1-4]

• The General Statutes of Connecticut [Volume 7, Title 20, Chapter 379 Sec. 20-114]

• The Delta Dental of New Jersey Participation Agreement

• The Delta Dental of New Jersey Dentist Handbook for Participating Dentists, Chapter 2, Rules and Regulations and Chapter 11, Claim Verifications

• The Fight Fraud section of our Web site, at www.deltadentalnj.com; click “Fight Fraud” on the left navigation bar

To report any suspected fraud to Delta Dental of New Jersey:

• Call our fraud hotline:
  (888) 696-3262

• E-mail: reportfraud@deltadentalnj.com

• Fax: (973) 944-4573

•  Write to:
  Delta Dental of New Jersey
  Special Investigations Unit
  1639 Route 10
  Parsippany, NJ 07054