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.
Roommate Assumes Member's Identity to Obtain Treatment (Pennsylvania)
On 3/04/09, the SIU received a case referral from Gateway Health Plan advising of an inquiry received from a member. The member advised that she received a Dental Explanation of Benefits from United Concordia for dental treatment she did not receive and suspected her former roommate of assuming her identity to receive the treatment. Based upon the allegation, the SIU obtained copies of the clinical records and radiographs from the treating dentist and confirmed that the treatment in question was not rendered to the member. On 3/25/09, the SIU referred the case file to the PA Attorney General’s Office. The referral included the identity of the member’s former roommate. On 2/24/10, the former roommate pled guilty to one count of Identity Theft and one count Theft by Deception. She was sentenced to three years of probation and ordered to pay restitution of $133.00 to United Concordia.
Former Dental Office Employee Submits False Claims (Arkansas)
On 9/11/08, the SIU received a call on the fraud hotline from a dental office advising that a former employee had submitted false claims for herself and her spouse. The provider advised that the claims submitted to United Concordia included a notation that requested the insurance reimbursements be issued directly to the patient. The SIU obtained claim and cancelled check copies and confirmed the allegation. On 11/07/08, the SIU referred the case file to the Arkansas Insurance Fraud Division. On 2/09/10, the former employee/TDP enrollee was convicted on one felony count; violation of Fraudulent Insurance Act. She was sentenced to 36 months of probation and ordered to pay restitution of $2,874.70 to United Concordia.
Former Dental Office Employee Steals from Dentist and Also Submits False Claims (Florida)
On 1/13/09, the SIU received a call on the fraud hotline from a dental office advising that a former employee had recently been arrested for stealing money from the dental practice. The provider advised that the case was active and being handled by the US Attorney’s Office. The provider further advised that subsequent to the former employee’s arrest, the provider advised that he discovered she also submitted false claims to United Concordia for herself and her children. The reimbursement for these false claims totaled $8,268.10. Based upon the information received from the provider, the SIU referred the case file to the US Attorney’s Office on 03/10/09. The SIU requested the US Attorney’s Office to include the false claims submissions with their active case. On 3/16/10, the former employee pled guilty to two counts; uttering forged bill and schemes to defraud. She was sentenced to five years of probation and ordered to pay restitution of $8,268.10 to United Concordia.
The Robin Hood Syndrome (Pennsylvania)
On 7/10/06, the SIU received a case referral from the Utilization Review (UR) department. UR identified this provider based on his high utilization of anterior restorations and as a result, audited 30 patient records. During the Dental Director’s review of the first patient’s records, he identified multiple restorations that were billed to United Concordia, but not documented in the chart. Instead, the chart documented the performance of a bridge. When the Dental Director questioned the provider about the inconsistency, he advised that he reported the restorations to United Concordia to cover the cost of the bridge, since the patient’s plan did not cover the bridge. The provider admitted he was in the wrong and advised that the pattern would be found in the remaining charts. The provider stated he submitted the false claims to help the majority of his patients whom he described as senior citizens with limited dental benefits and incomes.
On 9/13/06, the SIU initiated a fraud referral to the FBI, concluding that the provider committed fraud against United Concordia by intentionally reporting procedures that were not rendered for the purpose of obtaining reimbursement for completed procedures that were not a covered benefit. On 5/14/08, the provider entered a guilty plea to one count of Health Care Fraud. As part of the plea, the provider agreed to refund $94,098.89 to United Concordia. He was sentenced to 3 years of probation, to include 6 months of home detention, and was required to perform dental services to elderly and low income patients for 10 hours per month for one year.