Delta Dental’s mission is to provide quality dental coverage to its subscribers/members and their dependents and has done so since 1971. Since 1981, we have had an ongoing program of in-office reviews performed for dentists who submit claims to Delta Dental of New Jersey.

Delta Dental’s Special Investigations Unit (SIU) currently consists of nine individuals, each of whom is qualified under N.J.A.C. 11:16-6.4 (d)1, as well as support staff.  Pursuant to New Jersey state law, SIU investigators shall have at least one of the following:

• A bachelor's degree
• An associate's degree plus a minimum of two years experience with insurance-related employment
• A minimum of four years of experience with insurance-related employment
• A minimum of five years of law enforcement experience

Our SIU staff has a diverse educational and professional background relating to dental, claims processing, law, and public policy.  We currently meet or exceed the New Jersey state requirements. Delta Dental of New Jersey also utilizes other staff such as dental consultants, customer service agents, underwriting and claims processing professionals to assist in investigations.

The SIU is responsible for:

• Receiving written and verbal correspondence regarding suspicious claims and developing a course of action
• Conducting reviews of claims, treatment records, financial records, and other supporting documentation for both insured and uninsured patients
• Analysis of the records and claims to determine if there is evidence of misrepresentation regarding claim submissions
• Communicating with patients to determine if any misrepresentation occurred
• Reporting fraud to appropriate state agencies and bureaus
• Training Delta Dental associates on fraud prevention

Healthcare fraud is defined as an intentional deception or misrepresentation an individual or entity makes knowing that the deception could result in some unauthorized benefit or reimbursement.

Abuse is defined as incidents or practices of providers that are inconsistent with accepted business or financial practices and which result in unnecessary cost to an insurance carrier.

The State of New Jersey has had an Insurance Fraud Prevention Act in effect since 1983. It was revised over the years but had originally treated health care insurance fraud only as a civil offense.

However, as a result of the Automobile Insurance Cost Reduction Act of 1998 (AICRA), the New Jersey Health Care Claims Fraud Act was created. This act made healthcare fraud a criminal act carrying enhanced penalties.

Additionally, this law created the Office of the Insurance Fraud Prosecutor (OIFP), part of the New Jersey’s Division of Criminal Justice.  The OIFP raises awareness of fraud throughout the State and investigates and pursues violators.

Because of this law, insurance carriers who do business in New Jersey are required (under heavy penalty) to report all reasonable suspicions of fraud to the OIFP. Additionally, all health and automobile insurance companies must maintain special investigations units, and provide anti-fraud training to all their claims processing and underwriting staff.

For further details on how our SIU and fraud in general relates to providers, subscribers/members, and groups please utilize the following links:

Office of Insurance Fraud Prosecutor (New Jersey)
http://www.state.nj.us/oag/njinsurancefraud/index.html
877-55FRAUD
(877-553-7283)

New Jersey State Board of Dentistry
http://www.state.nj.us/lps/ca/medical/dentistry.htm
973-504-6405

Official Web Site for the State of New Jersey
http://www.state.nj.us

New Jersey Law Network
http://www.njlawnet.com/njstatutes.html

New Jersey Department of Banking and Insurance
http://www.state.nj.us/dobi/aboutdobi/htm