Delta Dental’s mission is to provide quality dental coverage to its subscribers/members and their dependents, and has done so since 1971. Since 1981, we have had an ongoing program of in-office reviews performed for dentists who submit claims to Delta Dental of New Jersey.
Delta Dental’s Special Investigations Unit (SIU) consists of a team of investigators, each of whom is qualified under N.J.A.C. 11:16-6.4 (d)1, as well as support staff. Pursuant to New Jersey state law, SIU investigators shall have at least one of the following:
Our SIU staff has a diverse educational and professional background relating to dental, claims processing, law, and public policy. We currently meet or exceed the New Jersey state requirements. Delta Dental of New Jersey also utilizes other staff such as dental consultants, customer service agents, underwriters, and claims processing professionals to assist in investigations.
The SIU is responsible for:
The State of New Jersey has had an Insurance Fraud Prevention Act in effect since 1983. It was revised over the years, but initially considered health insurance fraud as a civil offense.
Later, as a result of the Automobile Insurance Cost Reduction Act of 1998 and the New Jersey Health Care Claims Fraud Act, health care fraud was deemed a criminal offense carrying enhanced penalties.
Currently, the Office of the Insurance Fraud Prosecutor, part of New Jersey's Division of Criminal Justice, raises awareness about the consequences of fraud and investigates criminal fraud schemes. The Bureau of Fraud Detection, part of the New Jersey Department of Banking and Insurance, is charged with pursuing civil fraud.
In Connecticut, the Fraud and Investigations Unit of the Connecticut Insurance Department also pursues allegations of insurance fraud.
Because of New Jersey's statutory scheme, insurance carriers that do business in New Jersey are required (under heavy penalty) to report all reasonable suspicions of fraud. Additionally, all health and automobile insurance companies must maintain special investigations units, and provide anti-fraud training to claims processing and underwriting staff. Connecticut similarly requires insurers to report and investigate insurance fraud.