Who Can Commit Health Care Fraud and Abuse?
Acts of fraud can be committed by practitioners, office staff, subscribers/members and dependents, brokers, agents, and employer groups. Anyone who knowingly benefits from an act of insurance fraud is equally guilty of the offense of health care fraud.
Who Can Report Health Care Fraud and Abuse?
ANYONE can report fraud. In New Jersey, referrals can be made to the Office of the Insurance Fraud Prosecutor, the New Jersey Board of Dentistry, and to Delta Dental of New Jersey.
In a dental practice, there are many people who may be privy to the actual routines and habits of an office. For example, dentists and office staff have peers, spouses, and friends with whom they discuss their practice. However, the majority of our reports concerning health care fraud and abuse are received from members and patients. They may report fraudulent or questionable activities because of a disagreement with the office, a sense of ethics, or a guilty conscience.
Other Ways of Detecting Fraud and Abuse
fraud and abuse can also be detected in a variety
of other ways. The establishment of Special
Investigations Units and mandated anti-fraud
training for insurance carrier employees provided
on a regular basis have facilitated detection of
fraudulent claims or applications.
Some insurance carriers regularly audit various provider offices to verify the accuracy of claims submitted. Delta Dental also monitors all applications for dental insurance coverage. When an application is reviewed, Delta Dental obtains documentation that corroborates the applicant organization is a functioning establishment and is in fact eligible for coverage. The application is also reviewed to ensure it matches the terms and conditions of the proposal. For example, since premiums are quoted for a specific number of employees, Delta Dental will verify the number of employees reported for accuracy.
Why Do Individuals Commit Health Care Fraud and Abuse?