No. 21 May Term, 1979, Appeal from the Opinion and Order of the Commonwealth Court of Pennsylvania at No. 967 C.D. 1977, Dated January 11, 1979, Affirming the Order of the State Dental Council and Examining Board.
James W. Reynolds, David A. Wion, Harrisburg, for appellants.
William J. Wheeler, William H. Andring, Jr., Asst. Atty. Gen., for appellee.
Eagen, C. J., and O'Brien, Roberts, Nix, Larsen, Flaherty and Kauffman, JJ. Eagen, C. J., concurs in the result.
Appellants Dr. Thomas R. Snell, Dr. Charles M. Hughes, and Dr. Daniel K. Lovette challenge the order of the Commonwealth Court upholding the State Dental Council and Examining Board's suspension of their licenses. Appellants contend that insufficient evidence appears of record to support a finding of knowledge or intent to defraud Pennsylvania Blue Shield by submission of false claims. We agree with appellants and reverse the order of the Commonwealth Court.*fn1
From 1969 through 1971, appellants practiced oral surgery as salaried employees of the Miller Clinic in Harrisburg, Pennsylvania. The Clinic, owned solely by Dr. Richard Miller, provided oral surgery care to patients referred by general practitioners in that area. Many of the Clinic's patients were covered by Pennsylvania Blue Shield dental insurance policies. Thus, the Clinic received reimbursements from Blue Shield for such services. Appellants, as salaried
employees, were not directly affected financially by the amount of reimbursement the Clinic received.
Because the Clinic received reimbursements in excess of $10,000 for the years 1969, 1970, and 1971, Blue Shield reviewed Clinic records to determine the accuracy of the claims presented. Of approximately 30,000 claims submitted by the Clinic during this three year period, investigation of four hundred files disclosed only twelve possible false claims. Blue Shield contacted the referring dentists and obtained their "bite wing" x-rays, taken of the twelve patients prior to surgery at the Clinic. From these x-rays, Blue Shield concluded that appellants performed surgical removal of erupted teeth and then submitted claims to Blue Shield for removal of impacted teeth. Surgical removal of impacted, but not erupted, teeth was covered under the dental insurance plans.*fn2
As a result of these allegations, the State Dental Council and Examining Board cited appellants for violations of section 3(i) of the Dental Law.*fn3 After a hearing on the allegations, the Dental Council found that false claims had been filed and thus, that appellants had ...