On-Site Dental Visits Key to Combating Fraud

One way Delta Dental aggressively combats insurance fraud is through claim verification. Our Special Investigations Unit (SIU) team regularly visits dental offices to verify the accuracy of claims and ensure that the fees they file and charge our patients reflect the fees most frequently charged to their uninsured patients.

Many of these in-office reviews are the result of referrals made to our SIU department. We also monitor groups and subscribers. In the past, we performed more limited reviews of dental offices’ treatment and financial records. We advised offices of any issues found and the proper way to submit claims. If we made an overpayment, we recovered that money.

However, we noticed that some dental offices continued to submit claims improperly. These offices did not seem concerned about violating their Delta Dental participation agreement, the Bylaws of Delta Dental, New Jersey State Board of Dentistry Regulations, the General Statutes of Connecticut, the New Jersey Insurance Fraud Prevention Act, or the New Jersey Health Care Fraud Claims Act, which establishes health care claims fraud as a criminal offense.

Consequently, we have taken a more assertive role in deterring and detecting fraud. Today, when we perform an on-site dental office visit, we copy records so they can be fully reviewed and analyzed by an investigator. We request explanations of discrepancies, and review responses. We weed out office errors and educate office staff about proper billing procedures. If we find no evidence of improper billing, we close the matter.

But if we do identify improper billing, we take action to stop it and recover overpayments. This process may involve meeting with the dentist and the office staff. Most often, the parties reach an amicable settlement. Where the situation could not be resolved, however, Delta Dental has gone to court. We filed ten lawsuits over the past six years. Recently, Delta Dental has also insisted on terminating providers’ participation agreements where appropriate.

Over the past 14 years, Delta Dental of New Jersey has recovered more than $8.3 million due to fraud and abuse. Since Delta Dental is dedicated to serving the interest of our groups, self-funded group money received as restitution is refunded to the specific groups.

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], at www.njleg.state.nj.us/

• The General Statutes of Connecticut [Volume 7, Title 20, Chapter 379 Sec. 20-114], at www.cslib.org/psaindex.htm

• 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