Insurance fraud is a broad term that actually has many different forms, including:
Scams against government and private healthcare insurers are currently the largest type of insurance fraud. Although the exact amount is not known, it is estimated at tens of billions of dollars per year.
In some instances, fraud is easily detected but there are many instances where fraudulent conduct is difficult to identify and requires extensive investigations.
The SIU has a mandate during every investigation to determine if there is evidence of wrongdoing.
It is impossible to quantify the exact costs related to health care fraud today but it is currently one of the leading factors impacting health care costs in our country. Somewhere between 3 to 10 percent of total health care costs are related to insurance fraud, which translates into an estimated $80-$100 billion dollars per year. Imagine what could be done with that kind of money if it was not lost on insurance fraud.
Efforts are underway across the country, by several organizations to educate the public about dental and health insurance fraud. Knowledge is certainly a powerful tool in helping to deter this type of activity.
Insurance fraud is a crime and there is a great chance of getting caught. The consequences are very serious, including fines and prison time.
Patients, brokers, employers, and dentists all have an equal responsibility in identifying and fighting insurance fraud. These are just some of the signs:
Who Can Commit Dental Insurance Fraud?
Anyone who purposely benefits from an act of insurance fraud is guilty of committing health care fraud.
Who Can Report Dental Insurance Fraud?
Anyone! In New Jersey, if someone is aware of Dental Insurance Fraud occurring , they can report the information to the Office of the Insurance Fraud Prosecutor, the New Jersey Board of Dentistry, and Delta Dental of New Jersey.
Bottom line— there are many people who may have information regarding the routines and practices of a dental office. The dentists and their office staff have family and friends who have knowledge of the practice from discussions that take place at home or outside events, but the majority of reports concerning fraud are made by members and patients. The reasons for the report can be for any number of circumstances, such as:
Other Ways of Detecting Dental Fraud and Abuse
Dental Insurance Fraud or Abuse can be detected in a variety of other ways. Special Investigations Units uncover many instances, and mandated anti-fraud training for insurance carrier employees provided on a regular basis have facilitated detection of fraudulent claims or applications
Insurance carriers conduct routine audits of their provider offices to verify the accuracy of claims they receive. Delta Dental monitors all applications for dental insurance coverage and insures proper documentation is provided to verify they are eligible for coverage from a legitimate organization, and the number of employees reported is correct with regard to premiums quoted.
Top Reasons Why People Commit Dental Insurance Fraud