United Concordia's Special Investigations Unit (SIU)
is responsible for coordinating all fraud investigations with
various Federal and State law enforcement agencies. These
agencies include, but are not limited to, the Federal Bureau
of Investigations, Defense Criminal Investigative Service,
State Insurance Fraud Divisions, State Attorney General's
Offices, and United States Attorney's Offices. SIU relies
on various methods to detect unusual patterns that may indicate
fraud. These methods include data analysis, referrals
from patients/dentists, and anonymous sources. SIU
investigates all cases of suspected fraud and when
warranted, aids in the prosecution of individuals to
the fullest extent of the law. The following success
stories illustrate SIU's efforts to date.
May 2008
Dentist Pleads Guilty to Health Care Fraud
In May 2008, an Aliquippa, PA dentist plead guilty in
federal court to a one-count charge of Health Care Fraud.
In connection with the guilty plea, the Assistant United
States Attorney advised the court that from May 17, 2004
through May 25, 2006, the dentist made $94,098 in fraudulent
claims to United Concordia Companies, Inc. for reimbursement
of dental treatments and services to patients which were
either never performed or which were different than the
actual dental treatments and services performed.
The sentencing hearing is scheduled for September 24, 2008.
November 2005
Dentist Pleads Guilty to Theft Charges
In September 2005, a former Hanover Township,
PA dentist plead guilty to a total of 42 felony
counts consisting of theft and criminal attempt to
commit theft, and 37 misdemeanor counts of the same
crimes. In exchange for his guilty plea, the State of
PA, Deputy Attorney General withdrew 32 counts of
insurance fraud against him.
In November 2005, a Luzerne County Judge sentenced
the dentist to 2 1/2 to 5 years of imprisonment. The
Judge told him, he can not practice dentistry, or be
associated with any dental practice, as long as he
is in prison, on parole or serving his 15 years of
probation. The dentist is required to pay restitution
in the amount of $90,386 to various insurance companies
and patients who paid him out of their pockets. The
dentist, who is a native of Iran, could face deportation
from the United States following his imprisonment.
The dentist also faces more than 160 civil malpractice
lawsuits that have been filed by former patients
alleging that he performed shoddy dental work. Several
patients claimed he embedded broken dental tools in
their teeth causing them pain and suffering, according
to the civil lawsuits. At least eight civil lawsuits
are ready for trial scheduled to begin in early 2006.
October 2004
Dentist Found Guilty of Dental Fraud
On October 7, 2004, a Pittsburgh, PA dentist was
found guilty of encouraging assistants to perform
unnecessary procedures and bilking insurance
companies out of thousands of dollars. The U.S.
District Judge sentenced the dentist to four
years in federal prison followed by three years
of probation. The judge also ordered him to pay
restitution of nearly $200,000 to United
Concordia.
The dentist defrauded United Concordia of
$199,624 between August 1997 and April 2002 when
he filed claims for reimbursement of procedures
completed by his assistants. He would begin a
procedure and then allow his assistants to do
the filing and filling of the canal, which under
state law must be performed by a licensed dentist.
The assistants also administered Novocain and used
low-speed drills.
According to newspaper reports and eyewitness
accounts, the dentist directed his assistants to
perform and bill for the procedures, while he
slept in a back room. These employees were also
instructed not to complain about doing inappropriate
or unlawful tasks, as a condition of continued
employment.
The dentist's sentence should provide some
comfort and demonstrate that the justice system
will hold fraud perpetrators accountable for
their crimes.
The dentist first came to the attention of
United Concordia's Special Investigations Unit
as the result of an investigative demand. The FBI
sought information regarding the dentist's prior
aberrant billings to assist in their investigation.
This exchange and coordination of efforts ultimately
lead to federal charges, an indictment and subsequent
guilty plea.
United Concordia's Special Investigations Unit
takes all member, subscriber and client fraud complaints
very seriously and responds quickly. Our prompt,
responsive service helps to protect our customers
from fraud perpetrators, such as this dentist.
May 2003
Dentist Agrees to Pay $100,000 in Settlement of
False Claims Act Case
In May 2003, a Silver Spring, MD dentist agreed
to pay $100,000 to the government in settlement
of a case arising under the False Claims Act.
The dentist was also sentenced in U.S. District Court
to 2 years probation, 120 hours community service and
ordered to pay $18,553.60 in restitution, for a
federal criminal case arising from the same investigation.
The amount the dentist is required to pay in restitution
in the criminal case is offset against the $100,000
in damages and civil penalties that he must pay under
the False Claims Act.
The case arose as the result of an investigation
conducted by United Concordia Companies, Inc. and
TRICARE Management Activity. TRICARE is a federally funded,
statutory health benefits entitlement program for active
duty members of the uniformed services, their family members,
retirees, and survivors. TRICARE is administered by the
United States Department of Defense. United Concordia was
the dental plan contractor for TRICARE's health care
benefits plan.
The government alleged that from May 1997 through August
1999, the dentist submitted or caused to be submitted false
claims for reimbursement to TRICARE for dental work
allegedly performed on children who were family members
of uniformed services personnel. The government alleged
that the dentist submitted false claims, in the amount of
$8,250, for medically unnecessary periodontal scaling and
root planing performed on children ranging in age from
two years old to 15 years. Periodontal scaling and root
planing is a procedure used to treat periodontitis, a
gum disease which causes gum tissue at the base of the
tooth to separate from the root of the tooth. Periodontal
scaling and root planing is a painful and lengthy
procedure, often performed under local anesthesia, and
is not meant to be prophylactic in nature.
The damages and penalties in this case reached
$100,000 because the False Claims Act provides for
treble damages and up to $11,000 per count for each
submission of a false claim to a government-funded
health plan for reimbursement for medical or dental
services provided.
The investigation was conducted by the United
States Department of Defense, the United States
Attorney's Office in the District of Maryland
and the Special Investigations Unit from United
Concordia Companies, Inc.
