Success Stories - Archives

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

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 two 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.

July 2002

On July 17, 2002, a Freehold, NJ, dentist was sentenced in U.S. District Court, Newark, NJ, as a result of a January 16, 2002 guilty plea to a one count charge of both health care fraud and income tax evasion. He was sentenced to 27 months in prison and three years probation on each count, to run concurrently; restitution of $264,363.90; and a special assessment fee of $200.

The dentist first came to the attention of United Concordia's Special Investigations Unit (SIU) as a result of a complaint received from one of his patients. An investigation revealed that from as early as 1994, the dentist filed approximately $200,000 in fraudulent claims with various dental insurance companies for services that were not rendered. Among the dental insurance programs defrauded were the TRICARE Family Member Dental Program (TFMDP), administered internationally by United Concordia for the Department of Defense (DoD). The TFMDP has been replaced by the TRICARE Dental Program (TDP), also administered by United Concordia, providing dental benefits to dependents of active duty uniformed services personnel, including Reservists and their families, The TRICARE loss alone totaled approximately $20,000.

Furthermore, for the years of 1995, 1996, and 1997 combined, the dentist evaded $392,998 in federal income tax by submitting false tax returns to the Internal Revenue Service (IRS). In the three years combined, he underreported his income by $915,648.

June 2001

On June 1, 2001, a Colorado Springs, CO dentist was sentenced in Federal District Court, Denver, CO, to two years probation and ordered to pay $25,000 in restitution and a $5,000 fine. The sentence was the result of a February 15, 2001 guilty plea to making or causing to make a false statement or representations involving a Federal Health Care program.

Between January 1996 and December 1999, the dentist submitted numerous claims to TRICARE's contracted dental carrier, United Concordia Companies, Inc., Great-West Life, and Delta Dental for periodontal scaling and root planing that according to medical reviews, were not necessary. The procedure is performed and billed in segments of the mouth, or quadrants. The dentist submitted claims for quadrants of root planing and scaling for dates of service when patients were not present. He also submitted claims for periodontal pocket depth charts for scaling and root planing that contained measurements, patients said were not performed.

The investigation was conducted jointly by the Defense Criminal Investigative Service (DCIS), the Federal Bureau of Investigation (FBI) and with the assistance of United Concordia's Special Investigation's Unit (SIU). The prosecution was handled by the United States Attorney's Office, District of Colorado.

June 1998

In June 1998, a Fairfield, CA dentist plead guilty to a felony health care fraud and paid over a half-million dollars to settle federal civil charges. During a routine review of utilization statistics, United Concordia detected billing irregularities that ultimately led to federal prosecution. The case was one of the first in the nation to be prosecuted under the Kennedy-Kassenbaum federal health care statute.