Delta Dental caps fees for uncovered procedures

Should an insurance company be allowed to dictate what you can charge for procedures not covered by your patients' dental plan?

Delta Dental is the latest insurance carrier that seems to think so. Delta is implementing a new feature of its Premier and Preferred Provider Organization contracts that will require dentists to honor their contracted fees for services that are not covered by a subscriber's plan.

The provision will be introduced in a phased approach, with a national policy effective January 1, 2011.

"The availability of further enhanced and flexible dental benefit products will provide employers with increased opportunities to purchase dental coverage, offering more employees access to sound and professional oral health care," according to Delta's official statement. "This change translates to increased volume in dental offices as patients seek treatment previously deferred."

More than 50% of Delta Dental subscribers already employ this contract feature, and holding participating network dentists to contracted fees for noncovered services will create consistency across the national Delta Dental system, according to the company.

Delta also argues that while this policy is new to its contracts, it is not new to the industry or to many of its competitors.

There is concern, however, that the policy could negatively affect the way dentists do business. According to a recent post in the DrBicuspid.com General Dentistry forum, "if a procedure is not covered, the insurance company should have no input about fees or benefits. Seems like one more intrusion between the patient and doctor relationship."

According to Delta, any loss of income incurred by dentists as a result of this provision will be offset by increased patient utilization of services in the long run. "We estimate the financial impact of the noncovered services policy on a dentist to be minimal," said Tom Dolatowski, vice president of marketing and communications for Delta Dental.

Christopher Smiley, D.D.S., who serves on the ADA's Council on Dental Benefit Programs but is not an ADA spokesperson, disagrees. "This policy creates an inequity where the dentist is asked to share in the cost for a delivered service when Delta and the employer are not willing to do the same," Dr. Smiley said.

Dentists should contact the ADA's Contract Analysis service and review the ADA's information on the contract with their personal legal and financial counsel before entering a contract, he warned.

The company states that this move is a result of market need, so that patients going to Delta Dental participating dentists can save money on services not covered by their benefit plan. "Patient utilization may increase for services that were previously not covered, thus getting the treatment they need for better oral health without the financial burden," Delta said.

Dr. Smiley agrees that this plan is a result of a competitive market. Delta is creating value for its product in the eyes of the employer by limiting the out-of-pocket expense of the insured, he said.

However, the approach could be problematic.

"If a noncovered service is subjected to a mandated fee by Delta that is below what the treating dentist believes is fair and reasonable, the dentist may no longer offer that specific service to Delta patients, thus limiting their treatment options," Dr. Smiley said.

Delta has promised that it will only hold dentists to contracted fees for services where it has enough credible data to come up with a number. "For services where we do not have enough valid fee data, we will not put a contracted fee in place," the company assured.

However, lack of data might not be a prohibitive factor, according to Dr. Smiley. He explained that Delta has an extensive database and that some state Delta provider contracts require dentists to submit any service they provide to a Delta patient. If a code exists for that service, the dentist is obligated to submit a claim even if he or she is sure it will be denied.

"With such a policy, I assume Delta can amass enough data to determine prevailing fees for any and all services," he said.

Some uncovered services likely to be affected by this new provision include back-tooth tooth-colored fillings and crowns, sealants, veneers, tooth bleaching, and implants, Dr. Smiley noted.