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Delta Dental Plan Disclaimer

by David A. Hall, DDS

Dental insurance is a mixed blessing, and Delta plans are a great illustration of this. Practitioners have been increasing finding Delta Delta more and more difficult for dentists to deal with. We had some experiences with them in my final years practicing in Iowa, during 2000 to 2002, that showed them more toward focusing on increasing their profitability at the expense of the dental practices they supposedly existed to serve. They slipped a change through their rules during that time period that enabled them to significantly cut costs. It was legitimately voted on, but the overwhelming majority of dentists didn't realize what they were doing. Before the rule change, their fees were set by a survey of participating dentists. A little twist in the proposed language that was sent out to participating dentists disconnected the fee survey from the fee-setting process. The technicality was noticed by practically no one, and no one in authority in the dental association spoke up, so it quietly passed. What makes the fee-setting by Delta more significant, is that participating dentists agree to accept Delta's fees as payment in full for services, regardless of how serious the discount.

When Delta Dental started, the discounts enforced on dentists were minor and infrequent. However, many state plans have been moving toward deeper and more significant cost-trimming measures to where they are now, if they are completely followed, threatening quality of care.

In our office, we took a stand on several issues and refused to acknowledge their discounts on what we felt were solid grounds. For example, in Iowa, they decided they didn't want to pay for buildups on teeth that require crowns. I read the contract carefully, and it gives dentists the latitude to pursue an alternate non-covered treatment, with the patient's consent, and charge whatever fee the dentist feels is fair. When they threatened action against me because I was going against their policy, I boldly stated that I considered the non-payment of buildups a non-covered service, and I was therefore free to charge it.

In other actions, they determined that they weren't going to pay for periodontal maintenance procedures for more than a year past the original perio scaling appointment. They tried to get me to charge only for a regular cleaning, but I was determined to charge the full cost of the periodontal maintenance procedure and to get the patient on my side in doing so.

What I did to accomplish this, and to help insure me against action by Delta, is that I developed a disclaimer form for all my Delta patients. In the disclaimer, I specifically state these issues we had with Delta. I said that Delta did not want to pay for a buildup before doing a crown. I explained that I was taught in dental school that whenever we did a crown preparation, we were to remove all the restorative material from the tooth to make sure it was completely clean and free of decay. I explained that the American Dental Association had a separate insurance code for a buildup, and that it was recognized by them as a separate procedure, and the typical practice was to bill separately for it. I then wrapped up my comments by telling them, in the form, that I recommended that we do this buildup, but they needed to understand that it was at their full expense, since Delta wouldn't provide any benefits for the procedure. We then flagged the procedure so that it wouldn't appear on the insurance claim form.

I had a similar form for periodontal procedures, and asked for their agreement to the higher maintenance fee that wouldn't be covered by their dental plan. Almost all patients would agree to not be beholding to their insurance company recommendation because they trust us as their dental office.

We had a similar problem for highly esthetic anterior crowns that far exceeded Delta's allotment. We split the fee into an esthetic component and a restorative component. The fee for the restorative component was low enough to be covered by Delta. The esthetic component was given a miscellaneous code, and the patient was told that their insurance would not cover this. They would always choose the more esthetic crown and pay the difference. And Delta quit bothering us over this.

Here's the key when you're working with insurance companies and patients. If your patient understands your fee and what the insurance coverage will be before undergoing treatment, you will not have a complaining patient and all the efforts of the insurance company to alienate you from that patient will come to naught. However, if you surprise the patient with more to pay than was agreed upon, they may call on the dental plan to help defend them and you're the one in the vulnerable corner of the triangle, and you will lose.

Start with a disclaimer such as the following, and then expand it to be more specific about the treatment proposed and the payment expected. The disclaimer is easier to use if you have a dental practice accounting software like Dentech that keeps excellent track of exactly what certain dental plans are paying for certain procedures.

I understand the limitations of my dental plan as described above. If I or anyone in my family chooses a higher level of care than what my insurance covers, I agree to pay the amount not covered by my dental plan

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