The "Dark Truth" about Delta Dental...and why your company needs to drop them asap.

Before I start, let me be clear with what I do and why it matters to you. My husband and I work with dental insurance companies, insurance commissioners, state legislators, state dental associations, and representatives of the American Dental Association to ensure that both patients and their dental providers are protected against unfair and unethical practices by dental insurance companies. Why do we do this? Because there is no private entity in the US that exists simply to protect the quality of dental care with both the dentists and the patients they serve. There's a definite need, and we're here to fill it. My Practice My Business has been around since 2006, and we intend to remain practice advocates for years to come...

Recently, we were made aware that in addition to unethical changes Delta Dental has made in the past to positively affect their bottom-line, Delta Dental of Washington has been notifying their participating dentists that they cannot offer and charge for “enhanced” technologies and techniques, better materials, or medications to Delta Dental clients, despite the fact that these services are considered “non-covered” by insurance.?After further investigation over the last few months, I’m sad to say that this looks to be correct.?

First of all, it needs to be noted that when the insurance companies negotiate fees with their participating dentists, the fees are based on the “cheapest” way to do the procedure.?The contract states that reimbursement is made for the "Least Expensive Professionally Acceptable Treatment" (LEPAT). We understand that the insurance companies have shareholders to report to, and that definitely is a large factor in what is paid out in reimbursements to their dental providers.?On top of very low reimbursement rates, there are additional “tricks” that Delta Dental is using to further pad their profit margins:

Down-coding

Dentists are required to report services as they are performed, similar to how medical bills.?By doing so, the dentist can remain transparent with what was done and why.?For example, if a dentist does a 3-surface tooth-colored filling, there is a specific code and an agreed-upon fee between Delta Dental and the provider for a “baseline/cheap” tooth-colored filling that is charged out.?However, Delta Dental is allowed to change the code to reimburse for an even cheaper silver/amalgam filling, even though it was never done!?This affects your employees because they are under the impression that services are covered at a certain percentage rate by Delta Dental, but we know that the difference between what they say they cover and what they actually cover is a lot less!?This is easy to verify…just ask your Delta Dental representative if they have either an “alternate benefit” for services or if they “downgrade” services.

Bundling

Delta Dental will routinely identify a particular service/code that they feel they are paying too often (we call it “frequency”) and then they will make an internal decision to “bundle” that code into another service code in an attempt to pay less for the services actually performed.?As a result of this, separate services that used to be considered “covered” by Delta Dental are suddenly combined as “inclusive” by Delta Dental, and when they “bundle” those services, they will only pay for ONE of the two or more services.?All Delta Dental has to do when they decide to “bundle” services is make a change to their provider handbook (which can be done as much as twice a year) with little to no notification to the provider or patient.?Interestingly, the American Dental Association states that "bundling" of distinct services by dental insurance companies is considered to be "potentially fraudulent". In our opinion, there's nothing "potential" about it-it's fraud.

For example, “clinical crown lengthening” is a procedure that occasionally is needed to be done when decay has gone into the bone below the gum line.?Thankfully, it is not needed for a majority of crown procedures, but it is supposed to be billed when needed-it is a completely separate procedure.?Delta Dental states that it “covers” this procedure, but if it is done on the same day as a crown, it is considered “inclusive and not billable” in the provider handbook, meaning the additional charge for the additional service is required to be written off.?The only way it can be paid for (according to Delta Dental) is if the dentist numbs the patient, does the crown lengthening, then has the patient return on another day for the crown procedure!?Not only does this not make sense from a “patient care” perspective, but what patient wants to get numbed, worked on, then take time off on another day to do the rest of the work??

When the doctor insists on charging separately for services performed as they have before, they are accused of “unbundling” by Delta Dental and are threatened to be kicked out of network if they don’t write off the additional services rendered.?The dentist now has an ethical dilemma to make in the future: either do the needed service for free (thus losing money), or not offer the service at all.?Unfortunately, we see the latter too often.?We have had multiple reports of patients not receiving buildups with crowns, gingivectomies with crowns, clinical crown-lengthening with crowns, pulp caps with fillings, ridge preservation with extractions...the list goes on and on of services NOT being performed by the dentist because Delta Dental refuses to pay and will not allow billing of those services, even though there is a substantial increase in costs to the dentist/provider to do the additional procedure(s).

Forcing Write-offs Due to Services “Not Meeting Requirements”

When dentists go to school, they are trained to look for specific things that determine what services need to be done, and if certain services are needed, it is expected that the dentist documents the need for those services via x-rays, intra-oral photos, chart notes, periodontal charting, or other methods.?This is not without oversight by many entities, including the state's Department of Occupational and Professional Licensing.?If a patient or insurance company feels that “over-diagnosis” or anything similar is being done, then the State's Department of Licensing and Dental Board can be involved for discipline or license removal.

However, Delta Dental is changing those “standards of care” by stating that if their lower, "made up" standards are not met, then the procedure is not billable.?Dentists who have been trained to do a service when particular oral conditions are met are now being told indirectly to wait until the condition worsens before they can get paid for those services.?This is decreasing patient care and setting the doctor up for potential malpractice lawsuits in the future. An example would be periodontal disease. It's widely known in the dental industry that the insurance companies are requiring "worsened" conditions before they will pay on treating the infection that causes periodontal disease. Why is this important? Because periodontal disease shortens lifespans, is know to be fatal, and propagates a wide range of secondary medical conditions that could easily have been prevented with higher standards of care.

Now that the previous and current issues are being addressed, we are shocked at the most recent tactic by Delta Dental:

Delta Dental of Washington is now telling Dentists that they CANNOT offer and charge for “Enhanced" technologies and techniques, better materials, and advanced medications, all of which carry an increased cost of goods and direct operating costs to the dentist.

Per the American Dental Association, it is at the dentists’ discretion how to satisfy the CDT code.?If a dentist is only being reimbursed for a “basic/cheapest” way of doing a procedure (including baseline materials), then the dentist is allowed to perform the procedure in that manner, assuming that the dentist is doing everything clinically acceptable.?However, the ADA has also stated that “a decision to bill for ‘enhancements’ is a business decision that is not supported by a CDT code."? Simply put: there is no CDT code for medication, better materials, or advanced technology/techniques.?Because of this, the dentist has to create internal codes in the office to represent these enhancements, should he or she decide to offer them.?This is similar to a dental office offering an electric toothbrush or whitening.?They’re "not covered" by insurance and stay between the doctor/patient relationship. To clarify this point more, by creating internal codes in the office, the dentist can also remain extremely transparent with the patient when discussing and treatment planning additional charges for those "better" services or products.

In regards to “non-covered” services like those mentioned above, Washington State actually has a “non-covered law” that states that insurance companies are not allowed to dictate the fee for “non-covered services”.? As of the posting of this article, 44 states have "non-covered" laws, with the American Dental Association actively pursuing the passing of the Federal DOCS Act, which will apply a "non-covered services" law to federal dental plans, which currently do not have to adhere to state laws. In addition to the "non-covered" services law, Washington has an even stronger state law that prohibits dental insurance companies from interfering with a separate agreement for any service between the doctor-patient relationship.

Two years ago, we reached out to Delta Dental of Washington to ask about enhancements, and guess what??They gave their blessing as long as two things were done:

1.????The patient had to be educated on the enhancements

2.????The patient had to sign informed consent acknowledging and accepting the fee for the non-covered enhancements.?The only exception is medication, which is similar to fluoride-the patient just states that they want it or not verbally.

Delta Dental of Washinton also issued a statement back in 2013 indicating that technology, procedures, and materials that were considered “investigational” were by definition "non-covered" by the plan and the patient would be responsible for them if they chose them.?

Delta’s contract with dentists has 2 sections that also reinforces the patient’s right to decide what goes in their mouth:

1.????Discrimination: The dentist cannot discriminate against Delta Dental patients. Article 1, Section 5: "Neither Member Dentist nor DDWA will unfairly discriminate against any Enrolled Person in any manner."

2.????Non-Covered Services: Article 2, Section 11: The patient is allowed to choose “non-covered services” and if they choose those items, they must acknowledge and accept the additional fee in writing.

Now we get to the fun part: Delta Dental of Washington is now telling participating dentists that the fee agreed upon for each code includes the better materials, all meds, and technology/techniques and dentists are NOT ALLOWED to offer and charge for those additional services that go “above and beyond” basic services rendered. Again, the contract states that reimbursement is for the "least expensive professionally acceptable treatment". Do I sense a contradiction here?

They have stated in writing, “The contract between your office and DDWA clearly prohibits the practice of “unbundling” of services for treatments…It is the position of DDWA that resin-based composites, ceramics, and supporting materials used to fabricate and provide direct restorations and crowns are included in the standard fee for the completed procedure, and not eligible for an unbundling and upcharge”.

Let’s be clear about this: when additional medication, better materials, or new technologies/techniques that have increased costs of goods and direct operating costs are available (and they do not have CDT codes), they are considered a “value-added” service that goes above and beyond the basic way of doing a procedure and they are considered by definition to be “non-covered” services.?It is in no-way “unbundling” and anyone who accuses it of being “unbundling” is unfamiliar (or is simply uneducated/ignorant) with the definition.?

We have also done an independent survey of labs and dental supply companies in Washington State (as well as throughout the nation) and it confirmed that an overall majority of providers that are in-network with dental insurance companies are, in fact, ordering the “cheapest” materials and supplies available due to low reimbursement rates. Is this fair to patients????

Here’s the bottom line: it is UNETHICAL for any dentist to not offer choice when choice is available.?Your employees deserve to choose what medications are used as well as what "enhanced" materials, technology, and techniques are used.?When Delta Dental tries to tell dentists that they cannot offer those choices and be paid fairly for them directly from the patient, they are getting between the doctor-patient relationship and dictating the quality of patient care, which breaks a majority of state laws and their own contracts. One might think that's "practicing dentistry without a license"...and it certainly is unethical.

If the dentist is prohibited from offering Delta Dental patients choice in their oral healthcare, yet all other known dental insurance companies allow it, the dentist is blatantly discriminating against the Delta Dental patients, which violates their contract with Delta Dental. Yet, Delta Dental is insisting on the discrimination, which forces the dentist to breech their own contract. Article 1-Section 5: "Neither Member Dentist nor DDWA will unfairly discriminate against any Enrolled Person in any manner." Damned if you do...

So, what can you do about this??Delta Dental is not ashamed of bullying and intimidating their in-network dentists.?If a dentist resists these unethical changes, they will be removed from the provider network and lose patients.?HOWEVER, Delta Dental is very receptive to employer groups…especially yours.?

Your phone call to Delta Dental of Washington (or any Delta Dental plan in the US) is IMPERATIVE to ensure that Delta Dental redacts their statements on "non-covered" services and allows patient choice.?Call or write to Delta Dental’s CEO and COO and let them know that if they do not allow your employees to choose medication, enhanced materials, or advanced technology and techniques available to them, you WILL be taking your employees to an insurance company that does...and the majority of the "other" insurance companies do.?In fact, we currently are unaware of any other dental insurance company that doesn't allow patient choice. Shouldn't it be the public's choice when it come to their oral healthcare instead of the dictates of a dental insurance company?

When talking to the CEO/COO, ask that they respond IN WRITING that their participating dentists are allowed to offer and charge for medications, better materials, and technology to your employees and they will not get between the doctor-patient relationship. Be firm with this request because it's very easy for them to say one thing and dictate another. In addition, have them state in writing that any dentist that offers enhanced materials, non-covered technology/techniques, and medications to their clients (your employees) is not at risk of being removed from their network, as long as the patient is aware that those services are not Delta Dental’s responsibility and will be the patient’s responsibility, should the patient choose them. If Delta Dental cannot put this promise in writing, you definitely need to take your employees to another dental insurance company that will.

If you have any questions on the unethical practices of Delta Dental of Washington (or Delta Dental in other states), Dental State laws, dental insurance contractual agreements, or anything pertaining to this subject matter, please reach out to me.?In fact, I beg you to do so-this is the ONLY WAY we can increase the quality of patient care for your employees.?In addition, audio recordings, written documentation, and more is available upon request to your HR department, should you like to confirm any of the above information given. The more educated we can be on what’s being done, the more we can take a stand to help dentists in Washington State as well as dentists in other states and the patients they serve.

Washington State's "Non-Covered" Law

ADA Statement on "Bundling" (Page 18, section B)