Delta Dental of Rhode Island has been fined $25,000 after a review of the company's claims processes found it was not in compliance with some of the state's laws and regulations.
Beginning in May 2010, the Rhode Island Office of the Health Insurance Commissioner (OHIC) conducted an examination of the company's claims payment and claims denial activities after receiving 23 complaints from patients and dentists.
According to the resulting report, issued June 24, 2011, the examiners hired by OHIC found Delta Dental maintains adequate records, generally has good claims processing and customer service capabilities, and prepares and submits reports as required.
However, the examiners also noted several areas in which Delta Dental needs to improve and made 19 recommendations for changes in Delta Dental's policies and procedures. Several of these recommendations were adopted by Delta Dental in the course of the examination, according to the examiners.
In a related order issued by Commissioner Christopher Koller, the company was fined $25,000 and directed to carry out an audit verification program to ensure implementation of the examination report recommendations, and modify its quality management program.
"I appreciate the seriousness with which Delta Dental has taken this examination and its findings, and its commitment to fully implement the recommendations of the examination report," Koller stated in a press release.
According to a statement issued January 26 by Delta Dental:
The [OHIC] examination involved a review of 23 complaints made to OHIC during the examination period. Of the 23 complaints, 17 were from dentists -- 11 of whom were Rhode Island-based dentists -- and six were from consumers. Most of the complaints were based on procedural and process issues. In only one of the 23 cases did the OHIC examiners determine that a claim should be paid. During the timeframe in question, Delta Dental processed nearly 1.9 million dental claims and pre-treatment estimates and issued payments totaling more than $260 million to over 30,000 dentists across the country.
The OHIC examiners noted in their report that Delta Dental fully cooperated during the examination process, and the report also concluded that Delta Dental “maintains adequate records and generally has good claim processing and customer service capabilities.”
“From the start, we viewed the examination as an opportunity to improve our performance and provide better service and communications to our members and dentists,” said Delta Dental president and CEO Joseph A. Nagle. “Implementing these recommendations allows us to continue to make dental coverage accessible and affordable as well as protect our members when we become aware of instances of fraud and abuse.”
