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Delta caps rates nationally for two networks

Dr. Richard Homsey of Moore, Okla., says he'll think long and hard before he decides whether to sign new contracts effective January 2009 from Delta Dental.

"We see a lot of patients covered by Delta so if we don't sign these contracts we'll take a hit," Dr. Homsey told ADA News. "But when somebody tells you what you can charge for a treatment they don't even cover, you have to think twice about it."

A contract provision that holds dentists to Delta's maximum allowed fee for noncovered services will affect all of Delta's Premier and Preferred Provider Organization participating dentists throughout the country by January 2011. The provision is being phased in gradually, with subscribers and dentists already under the provision for some services in some states. It includes services a dentist provides after a patient has reached his or her annual maximum benefit.

Once the provision is fully in place, noncovered services subject to charges under Delta's contracted fee schedule will be consistent across the country. However, individual Delta companies will still determine allowable charges for noncovered services in each local market.

"We will only hold dentists to contracted fees for services where we have enough credible data to develop a contracted fee," says Delta's statement on the policy. "For services where we do not have enough valid fee data, we will not put a contracted fee in place."

Tom Dolatowski, Delta's vice president of marketing and communication, estimates that some 75 percent of dentists nationally are participating in the Delta Dental Premier plan, while some 25-30 percent are participating in the Delta Dental PPO plan.

He estimates that Delta Dental's fee levels average a 20-25 percent aggregate discount nationally for dentists in PPO plans and that the discounts average 2-5 percent nationally for dentists in Premier plans. In both the Premier and PPO networks, the discount level can vary significantly at the local level, according to Mr. Dolatowski.

"In the long run increased patient utilization of services may offset any loss of income dentists incur," said Mr. Dolatowski. He estimates the financial impact of the noncovered services policy on a dentist to be minimal. He says while the policy is new to Delta, it's not new in the industry among Delta's competitors.

Many dentists believe they should be able to charge their usual fees when an insurance company excludes coverage for a procedure.

"They're not doing this to be our partners," observed Dr. Homsey. "They're doing this to compete with other payers."

Dr. Christopher J. Smiley, a member of the Council on Dental Benefit Programs says Delta is in effect capping the fee a participating provider can charge a Delta insured patient for services Delta isn't otherwise covering.

"Setting a cap on patients' out-of-pocket billings prevents dentists from commonplace forms of claims filings," Dr. Smiley said.

For an example, in the past, a Delta Dental network dentist might exercise a contract's least expensive alternative treatment clause and substitute a service (a comparable-sized amalgam for a posterior resin restoration) on the explanation of benefits. The dentist would then balance bill the patient for the full price of the treatment. Under Delta's new noncovered services policy, any uncovered service is much like a covered service in that the dentist can only balance bill the patient up to a set fee. When no comparable service can be substituted (sealants, for example) and no Delta payment is provided, it still works the same: Delta restricts what the provider is able to bill based on claims data they have from other plans they administer.

Theoretically, participating dentists have been submitting claims for all services (covered or not) since they began participating. Some contracts even include a provision stating that a participating dentist agrees to submit a claim form for all services rendered to enrollees for which a charge is made. Mr. Dolatowski says the requirement is not a national policy, is not enforced or consistent among contracts and may have been included in contracts by local Delta companies interested in collecting data on services.

"Anything at all that's not covered should be submitted so Delta can get credible data to develop a contracted fee for services provided," says Dr. Smiley. "Some may have figured why go through the rigmarole when Delta isn't paying anyway. But now it's time to submit for everything, even bleaching. Use those CDT codes. Maybe that will help Delta accumulate the credible data needed to develop accurate contracted fees."

Dr. Jed Jacobson is on Delta's Dental Policy Committee and served on its noncovered services task force to gather information about which ADA codes Delta has enough credible data for to fall under Delta's national noncovered services provision. He says, in general, the services included are services already covered by Delta plans.

"Typically, services that aren't provided frequently enough for us to have meaningful data about or have fees that range all over the map, such as some cosmetic services, would be excluded," said Dr. Jacobson. Services difficult to develop a credible allowable fee for that Dr. Jacobson expects will be excluded include:

  1. services performed so infrequently that sufficient fee data is unavailable to establish a valid fee;
  2. services that don't compare in any reasonable way to the services falling under noncovered policies of Delta's competitors;
  3. services covered under the medical portion of a patient's plan;
  4. services typically listed as a contract exclusion under Delta contracts.

With enough fee data, an example of an exception to the fourth condition may be sealants, according to Dr. Jacobson.

"Certainly enough claims data can be collected for sealants, said Dr. Jacobson. "Sealants are reasonably ubiquitous, in comparison to some cosmetic services, where the services, as well as the charges are highly diverse."

Contract Analysis Service is free to ADA members

The ADA recommends that dentists utilize the ADA Contract Analysis Service before any new participating provider agreement is signed. The service is available free of charge for member dentists requesting an analysis through their constituent dental societies. Dentists contacting the ADA directly are charged a $50 fee.

More information on the ADA Contract Analysis Service is available for ADA Members on ADA.org, or contact your state dental society.

"Education about contracting provisions is a great tool," says Tamra Kempf, ADA's chief legal counsel. Ms. Kempf encourages members to take advantage of the Contract Analysis Service.

"It's also important to remember from a legal perspective that business decisions, including decisions about the method of practice, are personal choices that are to be made by individual dentists," says Ms. Kempf. "Dentists and their dental societies should consider positive advocacy paths and avoid actions that might create potential antitrust exposure for unlawful collective actions, such as price fixing or boycotts."