Fraud Success Stories

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.